Assignment 2 - Human Resource Management
Is it possible for a health policy to fail due to cultural factors? How important is it for the community to get involved with the decision-making process during policy development? After reading your Learning Resources this week, you will recognize the significance in cultural awareness and health policy development. For this Assignment, you consider community engagement in policy development.
To prepare for this Assignment, complete the readings and view the media in your Learning Resources. Consider the importance of beliefs and behaviors when developing health policies.
The Assignment (3 pages):
Explain the importance of culturally appropriate health policies.
Explain how one can develop a policy so that it gets the support of the community.
Explain how you might engage the community to be part of the voice when developing a policy.
Expand on your insights utilizing the Learning Resources.
Use APA formatting for your Assignment and to cite your resources.
Taiwanese medical students’ narratives of intercultural
professionalism dilemmas: exploring tensions
between Western medicine and Taiwanese culture
Ming-Jung Ho1 • Katherine Gosselin1 • Madawa Chandratilake2 •
Lynn V. Monrouxe3 • Charlotte E. Rees4
Received: 30 May 2016 / Accepted: 14 November 2016 / Published online: 26 November 2016
� Springer Science+Business Media Dordrecht 2016
Abstract In an era of globalization, cultural competence is necessary for the provision of
quality healthcare. Although this topic has been well explored in non-Western cultures
within Western contexts, the authors explore how Taiwanese medical students trained in
Western medicine address intercultural professionalism dilemmas related to tensions
between Western medicine and Taiwanese culture. A narrative interview method was
employed with 64 Taiwanese medical students to collect narratives of professionalism
dilemmas. Noting the prominence of culture in students’ narratives, we explored this theme
further using secondary analysis, identifying tensions between Western medicine and
Taiwanese culture and categorizing students’ intercultural professionalism dilemmas
according to Friedman and Berthoin Antal’s ‘intercultural competence’ framework:
involving combinations of advocacy (i.e., championing one’s own culture) and inquiry
(i.e., exploring one’s own and others’ cultures). One or more intercultural dilemmas were
identified in nearly half of students’ professionalism dilemma narratives. Qualitative
themes included: family relations, local policy, end-of-life care, traditional medicine,
gender relations and Taiwanese language. Of the 62 narratives with sufficient detail for
further analysis, the majority demonstrated the ‘suboptimal’ low advocacy/low inquiry
approach (i.e., withdrawal or inaction), while very few demonstrated the ‘ideal’ high
advocacy/high inquiry approach (i.e., generating mutual understanding, so ‘intercultural
Ming-Jung Ho and Katherine Gosselin contributed equally to this work.
& Lynn V. Monrouxe
[email protected]
1
Department of Medical Education & Bioethics, National Taiwan University College of Medicine,
Taipei, Taiwan
2
Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
3
Chang Gung Medical Education Research Center (CG-MERC), Chang Gung Memorial Hospital,
Linkou, Chang Gung Medical Foundation, 5. Fu-Hsing St., Kuei Shan Dist., Taoyuan City 333,
Taiwan, ROC
4
Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, VIC, Australia
123
Adv in Health Sci Educ (2017) 22:429–445
DOI 10.1007/s10459-016-9738-x
http://orcid.org/0000-0002-4895-1812
http://crossmark.crossref.org/dialog/?doi=10.1007/s10459-016-9738-x&domain=pdf
http://crossmark.crossref.org/dialog/?doi=10.1007/s10459-016-9738-x&domain=pdf
competence’). Though nearly half of students’ professionalism narratives concerned
intercultural dilemmas, most narratives represented disengagement from intercultural
dilemmas, highlighting a possible need for more attention on intercultural competence
training in Taiwan. The advocacy/inquiry framework may help educators to address similar
disconnects between Western medicine and non-Western cultures in other contexts.
Keywords Culture � Cultural competence � Intercultural competence � Professionalism �
Intercultural professionalism dilemmas
Introduction
In an era of globalization, healthcare practitioners must treat, work and communicate with
people from diverse cultural backgrounds. Cultural competence has been widely
acknowledged as essential to the provision of quality healthcare (Anderson et al. 2003;
Betancourt 2006). However, while cultural competence training has been incorporated in
Western medical curricula (Betancourt 2003; Brach and Fraser 2000), similar training has
yet to gain traction in non-Western medical education contexts. At the same time,
enamored with global migration and its attendant flows of culture, existing medical edu-
cation literature has tended to focus on ‘other’ or minority cultures within Western con-
texts. Current literature largely ignores the challenges experienced by non-Western
students learning Western medicine in non-Western countries, such as Taiwan.
Intercultural professionalism dilemmas in Taiwan
In Taiwan, research suggests that medical students are not well prepared to deal with
cultural issues encountered in patient care (Lu et al. 2014). Although brief educational
interventions have improved students’ cross-cultural communications skills, long-term
retention is of concern (Ho et al. 2008, 2010). Moreover, some quantitative assessments of
cultural competence based on Western frameworks have been found invalid or unreliable
in the Taiwanese context, which has raised the question of their applicability (Ho and Lee
2007). Still, existing notions of cultural competence in Taiwan tend to focus on encounters
with minority or ‘foreign’ cultures (Kleinman and Benson 2006), overlooking the chal-
lenges of Western medicine in Taiwanese culture. For medical students trained in Western
medicine in non-Western contexts, as in Taiwan, intercultural dilemmas may be more
pronounced.
Culture and cultural competence
Culture is a broad term used to signify patterns of belief and behavior, as manifest in
values, norms, practices, roles and relationships (Anderson et al. 2003; Betancourt 2003).
Far from denoting a singular group identity, each individual is a unique chimera of cultural
influences beyond simply race, ethnicity or religion (Betancourt 2003). By extension,
cultural competence implies the ability to operate effectively in interpersonal interactions
and contexts characterized by diverse cultural practices and beliefs (Betancourt 2006). This
ability has also been referred to as ‘cultural relativism’ (Sobo and Loustaunau 2010),
‘cross-cultural efficacy’ (Núñez 2000), ‘cultural humility’ (Tervalon and Murray-Garcı́a
430 M.-J. Ho et al.
123
1998) and ‘transnational competence’ (Koehn and Swick 2006). Earlier movements
towards cultural competence sought to impart students with cross-cultural knowledge and
skills (Kripalani et al. 2006; Altshuler et al. 2003) relying on cultural stereotypes and
oversimplifying inter- and intra-cultural heterogeneity (Koehn and Swick 2006; Dreher and
Macnaughton 2002). Recent approaches to cultural competence, however, have shifted
towards the integration of cultural background in the provision of empathic, individualized
care for patients (Tervalon and Murray-Garcı́a 1998; Koehn and Swick 2006; Dreher and
Macnaughton 2002).
Theoretical perspectives on intercultural competence
While many scholars have explored intercultural competence in teaching and learning and
healthcare contexts (Byram 1997; Leininger 1996; Srivastava 2007), we draw specifically
on Friedman and Berthoin Antal’s contributions from management studies to cross-cultural
communication (Berthoin Antal and Friedman 2008; Friedman and Berthoin Antal
2005, 2006). We chose this theory because of its action-orientated approach to intercultural
competence, drawing on concepts of action science and identity-based conflict (Friedman
and Berthoin Antal 2005). These authors define cultural competence as differing from
intercultural competence (Berthoin Antal and Friedman 2008; Friedman and Berthoin
Antal 2005, 2006). In their view, cultural competence denotes non-reflective action in
cross-cultural interactions; reliance on a set of learned skills, knowledge or assumptions
about ‘other’ cultures. Intercultural competence, on the other hand, involves ‘negotiating
reality’: a process of generating mutual cultural awareness and reflection through a careful
combination of high advocacy and high inquiry (Berthoin Antal and Friedman 2008),
where advocacy involves expressing and championing one’s own culture and inquiry
means exploring and reflecting upon one’s own and others’ cultures (Friedman and Ber-
thoin Antal 2005).
A high advocacy/low inquiry approach involves exhorting one’s own values without
considering those of others—not uncommon in healthcare settings, where one might
encounter ‘medicocentric’ practitioners (Campinha-Bacota and Munoz 2001; Pfifferling
1981) and hierarchical provider-patient relationships (Chandratilake et al. 2012). On the
other hand, a low advocacy/high inquiry approach involves exploring the views and values
of others without sharing one’s own views, with potential detriment to patient care. A low
advocacy/low inquiry approach can be interpreted as withdrawal or disengagement from a
cross-cultural encounter. The most desirable approach, according to Friedman and Ber-
thoin Antal, is high advocacy/high inquiry: an open exchange of views in the spirit of
exploration, discussion and mutual understanding (Berthoin Antal and Friedman 2008;
Friedman and Berthoin Antal 2005). Although the applicability of Western cross-cultural
frameworks is questionable in the context of Taiwan, due to a lack of existing indigenous
theoretical frameworks, we adopt Friedman and Berthoin Antal’s model as a heuristic
device to analyze our data without commiting to their conclusion that high advocacy/high
inquiry is ncessarily the best. The alternative to not using a Western theoretical framework
was to not use a theoretical framework at all. However, we decided against this theory-free
approach as we felt that theory would bring rigour to the qualitative analytic process (Rees
and Monrouxe 2010).
Taiwanese medical students’ narratives of intercultural… 431
123
Rationale and research questions
As medical education in non-Western contexts becomes increasingly Westernised, there is
a need to address any disconnects between Western medicine and non-Western cultures. In
Taiwan, while the formal curriculum in medical schools follows Western standards,
including formal teaching and assessment of Western professional codes and communi-
cation models articulating patient autonomy, confidentiality and informed consent, the
informal and hidden curriculum in clinical practice is affected by local culture. For
example, families play important roles in medical decision-making, to the degree of
compromising patient autonomy (Ho et al. 2012).
In line with existing models of cultural competence that encourage patient-centered
care, mutual understanding and joint decision-making (Betancourt 2006), we employed the
concept of ‘intercultural competence’ (Friedman and Berthoin Antal 2005) in our analysis
of Taiwanese students’ intercultural dilemma narratives. These narratives were elicited
through an exploration of students’ professionalism dilemmas: situations that they wit-
nessed or participated in, which they believe to be immoral, improper or unprofessional
from their own cultural perspective (Christakis and Feudtner 1993). Since medical students
frequently encounter professionalism dilemmas involving cultural differences, developing
cultural competence is key to students’ learning and practice of professionalism (Ho et al.
2008; Monrouxe and Rees 2012). This paper, therefore, addresses two research questions:
(1) Which aspects of Taiwanese culture are highlighted in students’ intercultural profes-
sionalism dilemma narratives? (2) Which combinations of advocacy and inquiry do Tai-
wanese medical students narrate in response to these dilemmas?
Methods
Study design
This study is part of a larger research project investigating Taiwanese medical students’
narratives of professionalism dilemmas. It employs qualitative narrative interviewing
(Monrouxe and Rees 2012; Monrouxe et al. 2014) and is underpinned by social con-
structionism, which conceptualizes knowledge as negotiated through social interaction and
acknowledges the existence of multiple realities (Crotty 2003). We therefore take a
qualitative interpretive approach in this study, despite identifying some basic quantitative
patterns in our data (Maxwell 2010).
Context
Taiwanese medical education is based on Western medical education (Ho et al. in press),
despite the cultural backdrop embracing both Western and traditional medicine to varying
degrees (Huang et al. 2014). Taiwanese medical degrees are typically seven years, and in
the participating school, year 4 students spend one afternoon per week learning to do
physical examinations and take patient histories. Year 5 and 6 students undertake clerk-
ships in different clinical departments, observing and taking on limited responsibilities in
patient care. Finally, year 7 students act as interns with direct but supervised responsi-
bilities in patient care.
432 M.-J. Ho et al.
123
Participant recruitment
Following ethical approval, we used electronic bulletin boards and assistance from student
association representatives to recruit participants. In total, 14 focus groups at one Tai-
wanese medical school were conducted with 64 students in 2013–2014 (15 females and 49
males, reflective of the school’s gender ratio) in Years 4–7 (age ranged from 20 to 33,
mean age = 24.5). The focus groups included 10 students from Year 4 (4 females, 6
males), 15 students from Year 5 (3 females, 12 males), 16 students from Year 6 (3 females,
13 males), and 23 students from Year 7 (4 females, 19 males).
Data collection
We employed a discussion guide based on previous studies conducted by two of the
authors (Monrouxe and Rees 2012; Monrouxe et al. 2014) in order to ensure consistency in
interviewing across the groups. After a general welcome to focus group participants,
introductions and a discussion of ground rules, we started each group discussion with an
orienting question: ‘‘what is your understanding of professionalism as a [state year]
medical student?’’. Then, participants were asked to share their professionalism dilemmas
based on their discussion of their definitions of professionalism. In the literature, profes-
sionalism dilemmas are defined as day-to-day experiences of students in which they wit-
ness or participate in an event that they find unethical, unprofessional, immoral or wrong
(Christakis and Feudtner 1993). Professionalism dilemmas include, but are not limited to,
ethical dilemmas. Once students’ professionalism dilemmas were exhausted, we closed the
interviews, thanking participants for their important contributions to the discussions and
asking them to complete a questionnaire before they left. This included basic demographic
(e.g. age, gender) and education-related details (e.g. year of study) so that we could define
the characteristics of our sample and each sub-group.
Data analysis
Group discussions were audio-recorded, transcribed, anonymized and entered into
ATLAS.ti Version 7.5.2 (Scientific Software Development GmbH, Berlin, Germany).
First, we identified personal incident narratives (i.e. stories of specific events) as the
primary unit for coding, rather than generalized talk (e.g. ‘‘it happens all the time…’’). In
total, 233 personal incident narratives were identified. A primary thematic analysis of this
data was undertaken using the five stages of framework analysis (Ritchie and Spencer
1994):
1. All authors familiarised themselves with the data independently (at least 6 transcripts
each) in order to identify themes and sub-themes. Note that two of five authors did this
in a deductive manner based on their knowledge of a previously developed coding
framework for professionalism from the UK and Australia (Monrouxe and Rees 2012;
Monrouxe et al. 2014). The other three authors engaged in this process in an inductive
fashion.
2. We came together to share our insights and to develop a mutually-agreed coding
framework. As intercultural dilemmas were among the most common themes
identified in students’ narratives, we decided at this point to undertake a secondary
analysis of intercultural professionalism dilemma narratives, which became the focus
of this paper. We then developed an additional coding framework for intercultural
Taiwanese medical students’ narratives of intercultural… 433
123
professionalism dilemmas (for example, what types of intercultural dilemmas did
students experience?) and employed Friedman and Berthoin Antal’s (2005) combi-
nations of advocacy and inquiry, to code the data.
3. The second author coded all intercultural professionalism dilemma narratives and a
research assistant double-checked the coding (see acknowledgements). Disagreements
were resolved through discussion with the first author.
4. The data were charted (i.e., patterns were explored within the themes).
5. These themes were interpreted in light of Friedman and Berthoin Antal’s (2005)
theoretical framework and existing literature.
Results
We identified 109 intercultural dilemmas, 98 (90%) of which referred to one or more
Taiwanese cultural issues and 10 (9%) to international cultural issues, as well as one
narrative (1%) referring to both (Monrouxe and Rees 2017).
Which aspects of Taiwanese culture are cited in students’ intercultural
dilemmas?
The following Taiwanese cultural themes were identified, with some narratives involving
multiple themes: (1) Family relations and role (n = 37); (2) Local policy (n = 33); (3)
End-of-life care (n = 15); (4) Chinese medicine (n = 15); (5) Gender relations (n = 11);
(6) Taiwanese language (n = 7); and (7) Other cultural issues (n = 8). See Table 1 for a
description of each theme and illustrative narratives.
Which combinations of advocacy and inquiry do Taiwanese students narrate?
Of the 109 intercultural dilemma narratives, 62 provided sufficient detail about interper-
sonal interactions to apply the advocacy/inquiry framework (see Table 2 for definitions and
examples). Below, we provide examples of the combinations of advocacy and inquiry
identified.
Low advocacy/low inquiry
Most of the students’ narratives reflected their reluctance to engage with Taiwanese cul-
tural dilemmas, though a few observed superiors taking the same approach. Interestingly,
students often expressed uncertainty or disappointment in such cases. In a narrative
combining end-of-life care, the role of the family and Chinese medicine, a Year 7 student
shared that her own relative, while taking blood thinner for a pulmonary embolism, began
to use Chinese medicine. The student suspected that the combination of Western and
Chinese medicines led to her relative’s death:
I participated in a traditional medicine club in the university… So I learned… that
there… [is] some research about… ginseng and… dong-quai hav[ing an] anticoag-
ulation effect. (Y7F2)
Yet, upon hearing of her relative’s death, she chose not to get involved:
434 M.-J. Ho et al.
123
Table 1 Descriptions of intercultural dilemmas in Taiwan with illustrative narratives
Cultural issue Description Illustrative intercultural dilemma narrative
Family
relations
and role
In Taiwan, families play an important role
in patient care and decision-making.
Without the patient’s knowledge, families
may make life-saving or life-ending
decisions. They may also choose not to
inform the patient of fatal diagnoses (Hu
et al. 2002; Tang et al. 2006)
‘‘The patient’s family did not want her to
know the condition because they think
that the poor old lady would collapse
when she knew that she had terminal
cancer… there was [a]a visiting staff who
was treating the lady with me, but he
decided not to tell the patient about her
condition… because I think he… didn’t
want to mess up the relationship with the
family and he wanted to respect the
opinion of the family, but… I’m not
sure… because I… [could] not ask the
patient if she wanted to know the truth
because her son or her grandson was
always there with her.’’ (Y7M2)
b
Local policy
and
legislation
Constraints on human and financial
resources imposed by the National Health
Insurance system place significant
pressures on Taiwanese healthcare
providers (Chi and Huang 2006; Chien
et al. 2012). Insurance policies can create
dilemmas for practitioners as they
consider the best course of treatment,
which may not always be covered by
insurance. Local laws can also cause
dilemmas in relation to reporting patients’
illicit drug use or women’s abortion
requests
‘‘I [wasn’t]… in the clinic with my dad [a
doctor], but […] later [he told me that]…
he saw the patient [who wanted to have
an]… abortion… She [found]… my dad
to [give her the] abortion, [but]… my dad
[couldn’t]… find [out who was] the real
dad… [which is needed to get permission
for an abortion in Taiwan]. So, the patient
shouldn’t have the abortion, but because
of the patient’s economic status, [she]
cannot afford that child, so it’s a very
difficult dilemma for my dad [whether to
give] her [an] abortion… or not. He just
g[a]ve the… girl [an] abortion because it
[was] a very difficult things for him to
figure it out.’’ (Y4M4)
End-of-life
care and
death
For many Taiwanese, discussions of death
are taboo (Wen et al. 2013). Families may
refuse to discuss death and opt to
withhold information about fatal
diagnoses from patients (Hu et al. 2002)
‘‘It’s very common in the palliative ward in
our hospital… most, like, for the elderly
people. They have very protective
children… [who] feel… if they know they
have cancer they cannot accept that… it’s
a cultural norm in our society… our
society is really afraid of talking about
death, especially for the older
generation.’’ (Y5F2)
Traditional
medicine
Traditional Chinese medicine is widely
used in Taiwan and covered by Taiwan’s
National Health Insurance (Chen and
Chang 2003; Chi 1994). Healthcare
professionals trained in Western
biomedicine have little knowledge of
traditional medicine
‘‘When you ask them [i.e., patients], they
always say ‘no… I don’t take Chinese
medicine’… but they just don’t tell you,
and even [if] they say ‘yes’, they don’t
know what kind of medicine that is…
They might tell you some very weird
name that you have never heard before
and even [if] you go online and check it…
it’s hard to get any information.’’ (Y7F1)
Taiwanese medical students’ narratives of intercultural… 435
123
I didn’t explain that to the family… because I think it’s the patient’s daughter that
suggest[ed] that… [her] father should seek… traditional medicine… They… don’t
know that traditional medicine also include[s] some anticoagulation effect. (Y7F2)
This student’s familiarity with Chinese medicine was, however, uncommon. Most
students, having been trained in Western biomedicine, expressed little interest in learning
Table 1 continued
Cultural issue Description Illustrative intercultural dilemma narrative
Gender
relations
and norms
Many Taiwanese are conservative when it
comes to allowing someone of the
opposite sex to view intimate body parts,
potentially causing discomfort for both
patients and students
‘‘One time I [went] to the bedside. We were
going to perform [a] physical
examination, but the patient was female
and she refused to [allow] that male
medical doctor to practice on her,
especially [since] we need[ed] to do the
heart and the chest part… Taiwan people,
especially female patients, feel very
uncomfortable for [a] male to do a
physical examination on those kind of
body part. So it’s really hard to, for male
medical students to get a real first-hand
experience of how to do physical
examination on the female patients.’’
(Y4M6)
Taiwanese
language
Though Taiwanese language is widely
spoken, the younger generation is less
proficient due to the prioritization of
Mandarin in the public sphere and as the
language of instruction in schools.
Furthermore, English and Mandarin are
the languages of instruction in Taiwanese
medical schools. Communication with
Taiwanese-speaking patients about
medical conditions can therefore pose
serious challenges (Beaser 2006)
‘‘Our Taiwanese [is]… usually not that
good… so, especially when we [are
talking about]… diseases or… nouns
[related to our profession],… it is difficult
to explain to them [i.e., the patients].’’
(Y5F3)
Other cultural
beliefs and
practices
Other cultural beliefs and practices range
from discomfort in examining patients’
intimate body regions (regardless of
gender) to dealing with hierarchy in the
Taiwanese healthcare setting, where
senior healthcare professionals may be
dismissive of their subordinates’ opinions
and ideas
‘‘I challenged my professor once just one
month after I came back from [names
overseas school]… My professor said that
to take a history you need to be
straightforward, and you need to be short,
like 2 min[s] to 3 min[s]. But I like to sit
on the bedside and then talk to the patient
and also the family. So when I start[ed] a
conversation I would just say ‘oh, how is
everything going?’ And the professor
behind me just said, ‘Why are you saying
that? That is not useful’… so they blamed
me in front of the patient, so after…
[being blamed a lot], I just sort of cr[ied].
Yeah, that was a terrible situation.’’
(Y5M3)
a
Square brackets indicate words inserted to clarify meaning or to correct mistakes in students’ spoken
English. Ellipses (…) indicate words omitted for clarity or brevity, or in cases of repetition or English errors
b
Y7M2 refers to Year 7, male medical student, number 2
436 M.-J. Ho et al.
123
about traditional medicine. One student shared that, instead of inquiring further when a
patient mentioned Chinese medicine:
I just write [it down], but I think nobody cares about that as long as it is not some
kind of toxin. (Y5M4)
Due to cultural taboos surrounding death in Taiwan, the families of critically ill and elderly
patients often make important end-of-life decisions without consulting patients. A Year 7
student shared the story of a patient with cancer whose family, rather than telling the
patient about his condition, waited until he was in a coma to sign a ‘do not resuscitate’
order. The student expressed discomfort with this practice, saying:
but that doesn’t make sense, because we should let the patient know that he will [not
be resuscitated]… but I think in… Taiwanese culture, this situation is really com-
mon. (Y7M5)
The student observed that a low advocacy/low inquiry response is common among medical
students faced with this type of dilemma:
some of the medical students will just withdraw… because they d[o]n’t want to face
that strange situation. (Y7M5)
Table 2 Advocacy/inquiry framework—Definitions and sample quotations
High advocacy/low inquiry (n = 11; 18%) Low advocacy/high inquiry (n = 7; 11%)
Definition: Exhorting one’s own views and values
while ignoring others’ perspectives (Friedman and
Berthoin Antal 2005).
Example: ‘‘I know one professor… he really…
[doesn’t] like Chinese herbs, and he has told us
that Chinese herbs… [are] nothing. It is truly
nothing in his mind… He… [doesn’t] want to hear
the patient if he or she… is taking… Chinese
medicine.’’ (Y6M14)
Definition: Respectfully exploring the views and
values of others while concealing or suppressing
one’s own perspectives (Friedman and Berthoin
Antal 2005).
Example: ‘‘As his physician, we can just support his
choices [to use Chinese medicine]… if that’s the
thing he want[s] to do before he die[s], then we
will respect it… so we just [said] ‘okay, if that’s
your choice, we will respect that’… it’s something
about the autonomy of the patient.’’ (Y6F3)
Low advocacy/low inquiry (n = 35; 56%) High advocacy/high inquiry (n = 9; 15%)
Definition: Hiding one’s own views and values while
failing to engage with others’ perspectives; also,
observing or withdrawing from a cross-cultural
encounter (Berthoin Antal and Friedman 2008)
Example: A student does not engage with patients
about their use of Chinese medicine ‘‘because
maybe I just think it’s not really my business.’’
(Y4M1)
Definition: Mutually and openly stating one’s views
and reasoning; inviting inquiry and discussion in
order to better understand one another’s
perspectives and to jointly devise a way forward
(Friedman and Berthoin Antal 2005)
Example: Regarding Chinese medicine, a student
says, ‘‘we cannot really deny those therapies,
because maybe they really [are] …
RESEARCH Open Access
A comprehensive review of HIV/STI
prevention and sexual and reproductive
health services among sex Workers in
Conflict-Affected Settings: call for an
evidence- and rights-based approach
in the humanitarian response
Alyssa Ferguson1, Kate Shannon1,2, Jennifer Butler3 and Shira M. Goldenberg1,4,5*
Abstract
Background: While the conditions in emergency humanitarian and conflict-affected settings often result in significant
sex work economies, there is limited information on the social and structural conditions of sex work in these settings,
and the impacts on HIV/STI prevention and access to sexual and reproductive health (SRH) services for sex workers. Our
objective was to comprehensively review existing evidence on HIV/STI prevention and access to SRH services for sex
workers in conflict-affected settings globally.
Methods: We conducted a comprehensive review of all peer review (both epidemiological and qualitative) and grey
literature published in the last 15 years (2000–2015), focusing on 1) HIV/STI vulnerability or prevention, and/or
2) access to SRH services for sex workers in conflict-affected settings. Five databases were searched, using
combinations of sex work, conflict/mobility, HIV/STI, and SRH service terms. Relevant peer-reviewed and grey
literature were also hand-searched, and key papers were cross-referenced for additional material.
Results: Five hundred fifty one records were screened and 416 records reviewed. Of 33 records describing
HIV/STI prevention and/or access to SRH services among sex workers in conflict-affected settings, 24 were
from sub-Saharan Africa; 18 studies described the results of primary research (13 quantitative, 3 qualitative,
2 mixed-methods) and 15 were non-primary research (e.g., commentaries, policy reports, programmatic
manuals). Available evidence indicated that within conflict-affected settings, SWs’ capacity to engage in HIV/
STI prevention and access SRH services is severely undermined by social and structural determinants including
widespread violence and human rights violations, the collapse of livelihoods and traditional social structures,
high levels of displacement, and difficulties accessing already scant health services due to stigma,
discrimination and criminalization.
(Continued on next page)
* Correspondence: [email protected]
1Gender and Sexual Health Initiative, British Columbia Centre for Excellence
in HIV/AIDS, St. Paul’s Hospital, 608-1081 Burrard Street, Vancouver, BC V6Z
1Y6, Canada
4Faculty of Health Sciences, Simon Fraser University, Blusson Hall, 8888
University Drive, Burnaby V5A 1S6, Canada
Full list of author information is available at the end of the article
© The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Ferguson et al. Conflict and Health (2017) 11:25
DOI 10.1186/s13031-017-0124-y
http://crossmark.crossref.org/dialog/?doi=10.1186/s13031-017-0124-y&domain=pdf
mailto:[email protected]
http://creativecommons.org/licenses/by/4.0/
http://creativecommons.org/publicdomain/zero/1.0/
(Continued from previous page)
Discussion/Conclusions: This review identified significant gaps in HIV/STI and SRH research, policy, and
programming for conflict-affected sex workers, highlighting a critical gap in the humanitarian response. Sex
worker-informed policies and interventions to promote HIV/STI prevention and access to HIV and SRH services
using a rights-based approach are recommended, and further research on the degree to which conflict-
affected sex workers are accessing HIV/STI and SRH services is recommended.
A paradigm shift from the behavioural and biomedical approach to a human rights-based approach to HIV/
STI prevention and SRH is strongly recommended.
Keywords: Sex work, Conflict, Post-conflict, Sexual and reproductive health, HIV/Aids, STIs
Background
Forty armed conflicts were active in 2014, an 18%
increase when compared to the 34 reported in 2013,
with many additional countries currently considered
fragile states, or involved in post-conflict rehabilitation
[1]. Armed conflicts have resulted in unprecedented
waves of population displacement as well as other dele-
terious human rights, public health, and social impacts,
including the disruption of traditional social structures,
a breakdown in security, and weakened or collapsed
health systems [2–5].
Roughly 50% of the estimated 43 million people made
refugees or displaced by conflict are women [6]. While
the relationship between conflict and HIV/STI preva-
lence in the general population is greatly shaped by
contextual factors [7, 8], and has been found to vary by
setting, women have been shown to often be dispropor-
tionately vulnerable to the negative health and social
consequences of displacement [9, 10]. The economic, so-
cial and political instability of conflict and post-conflict
environments, including social and physical displace-
ment, loss of traditional economic options, cultural up-
heaval, family separation and increased women-headed
households, often result in conditions that facilitate sig-
nificant engagement in sex work as a source of income,
particularly for women. Further, armed conflict and the
highly policed and militarized environment characteristic
of post conflict have been linked to widespread gender-
based violence (including rape as a weapon of war; forced
abductions), rights violations of women [3, 11–17], and re-
duced access to, or the interruption of, HIV and sexual
and reproductive health (SRH) programmes [4, 18–21].
For example, previous research has shown that within
conflict settings, the interruption of condom distribution,
disruption of HIV diagnostic services, and shortages of
HIV antiretroviral therapy (ART) may drastically impede
diagnosis and care [18]. Together, these dimensions of
conflict create a complex and challenging situation for
prevention of HIV/STIs and delivery of care to conflict-
affected populations [10], yet the lived experiences of sex
workers, conditions within post-conflict environments,
and barriers to accessing HIV and SRH services have
largely been unaddressed in research and policy. Further-
more, that programmers and development partners in
humanitarian settings may be uninterested in sex work or
may conflate issues of sexual exploitation with sex work
for ideological or political reasons, creates perverse
barriers in the protection of human rights for this group.
Sex workers are a key population disproportionately
affected by HIV/STIs [22]. While the majority of sex
workers globally are women, there are sizable popula-
tions of men and transgender sex workers in many set-
tings [23–25]. HIV/STI prevalence among sex workers
varies both across and within regions due to structural
factors related to the social, political, economic, legal, and
cultural conditions in which sex workers operate, in con-
junction with local HIV and STI epidemics [9, 22, 26].
Despite this, research and programmes in the past decade
have largely focused on behavioural and biomedical inter-
ventions among SWs, which alone, have had only modest
effects on the reduction of HIV at the population-level
[22, 27]. A recent global review identified a critical need
for further studies examining structural HIV/STI risks or
access to care for sex workers in the highest-HIV burden
countries [9], to inform the design, adaptation and imple-
mentation of effective HIV/STI programmes, particularly
needed within conflict-affected settings of sub-Saharan
Africa. While sex workers are often highly marginalized
even in non-conflict settings, in conflict-affected environ-
ments they may face elevated social and structural risks
and barriers to care, including abuses of human rights by
military and police, gender-based inequities, widespread
violence, discrimination and stigma, social and physical
isolation, breakdowns in health service delivery systems,
and other structural risks that often accompany or follow
a crisis [11, 14, 26, 28, 29]. Despite this, little is known
about conflict-affected sex workers’ vulnerability to HIV/
STIs or access to HIV and SRH services, or their social
and structural drivers within conflict-affected settings.
Given the paucity of existing data regarding HIV/STI risks
and access to HIV and SRH services within the context of
sex work in conflict-affected settings, this comprehensive
review aimed to broadly explore and synthesize current
evidence on HIV/STI risk, access to HIV and SRH
Ferguson et al. Conflict and Health (2017) 11:25 Page 2 of 20
services, and their social and structural determinants
within the context of sex work in conflict-affected settings
(i.e., conflict and post-conflict conditions).
Methods
Search strategy
From May to July 2015, we comprehensively searched
the peer-reviewed and grey literature for material
describing HIV/STI risk or prevention and/or access to
HIV or SRH services for sex workers in conflict-affected
settings in the last ten years. Five databases (PubMed,
Global Health, PAIS International, Social Sciences
Citation Index, and Web of Science Core Collection)
were searched using combinations of terms related to
sex work, conflict, HIV/STI risk or prevention, and HIV
and SRH services access related terms (Table 1).
Relevant journals and organizational websites were
hand-searched, and key papers were cross-referenced.
Due to the limited number of relevant peer-reviewed
studies available, grey literature (e.g., governmental and
non-governmental reports) was searched. Studies
conducted with populations of relevance other than sex
workers (e.g., Internally Displaced Persons (IDPs), clients
of sex workers) were also considered and included where
they provided useful context and insight regarding sex
work and HIV, STI, or SRH issues in conflict-affected
settings. The first and second rounds of screening in-
volved reviewing titles and abstracts, respectively, to
identify potentially relevant studies. The third-level of
screening consisted of a full-review of remaining records
to ascertain relevance in relation to the inclusion cri-
teria. We used the PRISMA guidelines as a reference
(Fig. 1).
Inclusion criteria
Eligible records included peer-review publications
(qualitative, quantitative, or review articles) or grey
literature (e.g., policy documents, community reports,
commentaries, issue reports and briefs, position reports,
practical guides for staff working in conflict/post-conflict
environments) that met the following criteria: 1) English
literature; 2) published from January 2000–July 2015; 3)
discussed sex workers (or their clients) working within
conflict or post-conflict settings (e.g., refugee or intern-
ally displaced sex workers); and 4) included data on
HIV/STI risk, prevention, or HIV and SRH services for
sex workers in conflict-affected settings. Other reviews
were included, as they synthesized key insights in a do-
main with a paucity of empirical studies. For the purpose
of this review, the United Nations definition of sex work
was adopted, defined as the sale or exchange of sex for
accommodation, protection, food, gifts and other items
or services. Studies which were explicitly and solely
focused on transactional sex (i.e., broader populations of
those who exchange sex for favours or gifts, or who do
not necessarily self-identify as sex workers) were ex-
cluded. Studies of the trafficking in human beings for
the purposes of sexual exploitation were also excluded,
unless they included the experiences of sex workers.
Conflict-affected sex workers included those who identi-
fied as refugees or IDPs from conflict or post-conflict
settings (defined as ≤10 years post-conflict) as well as
sex workers currently operating in conflict-affected (i.e.,
current or post-conflict) settings.
Data extraction and analysis
Endnote was used to manage retrieved items. A Microsoft
Excel database was developed to organize and chart study
characteristics (authors, year, country, design, population,
sample size), key findings, and the following data, where
applicable: HIV/STI prevalence, conflict-related variables,
qualitative findings, and key programme and policy
recommendations. We began by grouping the findings of
the epidemiologic studies according to common topics
and structural determinants, comparing them across stud-
ies. Next, we elicited common themes from the qualitative
data and compared these across settings. Lastly, we ana-
lyzed existing refugee and sex worker HIV/STI prevention
and SRH programme and policy recommendations in
conflict settings, seeking to draw lessons and exemplars
for future programmes and interventions.
Results
Five hundred and fifty-one titles and abstracts were
screened by the first author to determine eligibility. Four
hundred and sixteen eligible records were reviewed. Of
the 33 records which met the criteria to be included in
this review, the majority (n = 22) described conflict or
Table 1 Search terms
Sex work “sex work*” OR “prostitute*”
OR “transactional sex” OR
“commercial sex” OR “sex trade” or “FSW*”
Conflict environment “conflict” OR “emergenc*” OR “IDP” OR
“displaced” OR “displaced person*” OR
“displaced people” OR “refugee*” OR
“humanitarian” OR “war”
HIV/STI risk or prevention,
and HIV and SRH services
“HIV” OR “human immunodeficiency
virus” OR “HIV infections” OR “AIDS” OR
“acquired immunodeficiency syndrome”
OR “acquired immune deficiency
syndrome” OR “sexually transmitted
infections” OR “STIs” OR “Sexual health
services” OR “sexual health” OR
“reproductive health” OR “testing” OR
“test” OR “treatment” OR “ART” OR “ARVs”
OR “sex education” OR “sexual health
education” OR “safer sex” OR
“contraceptives” OR “birth control” OR
“family planning” OR “pap smear” OR
“condoms” OR “health services” OR
“health care” or “healthcare”
Ferguson et al. Conflict and Health (2017) 11:25 Page 3 of 20
post-conflict environments in sub-Saharan Africa, 4 were
from other settings (e.g., Afghanistan, Bangladesh/
Myanmar, Sri Lanka, and Nepal), and 7 were globally
focused. Eighteen studies described the results of peer-
reviewed primary research articles (13 quantitative, 3
qualitative, 2 mixed methods) (Table 2), and 15 were
non-empirical research (e.g., review articles, commentar-
ies, issue reports and briefs, position reports, and prac-
tical guides for staff working in conflict/post-conflict
environments). A summary of practical guides for staff
working in conflict/post-conflict environments (n = 5)
are described in Table 3. Twenty four of the 33 records
were peer-reviewed, while 9 were classified as grey litera-
ture/non-peer reviewed. Of the 33 included studies, 14
focused primarily on sex workers in conflict/post-con-
flict settings, while others discussed broader dynamics of
sex work (e.g., sex purchasing) among the general
conflict-affected population (n = 17), sex workers’ clients
(e.g., migrants, combatants) (n = 5), or a combination of
these groups. While eligibility was inclusive of all gender
and sexual orientations, the majority of studies reported
on cis-gender female sex workers. One study reported
on sexual and gender minority sex workers in displace-
ment and post-conflict settings [23].
Sex work context and links to HIV/STI prevention and risk
in conflict-affected settings
Sex workers in conflict and post-conflict settings were
found to face an extraordinarily high HIV and STI
burden. The burden of HIV among sex workers in studies
reviewed ranged considerably, with prevalence rates of
70% reported among Nepalese sex workers returning from
India [30], and 22.3% among conflict-affected sex workers
in Gulu, northern Uganda [31]. STI prevalence also
ranged considerably, with an acute self-reported STI
prevalence of 40.3% in Gulu, Uganda [31], and 17% of sex
workers in northern Ethiopia self-reporting history of an
STI [32]. Gonorrhea was the most common STI reported
in this study, accounting for 45.8% of the total [32].
Gendered economic impacts of conflict and sex work entry
Available data indicated high rates of sex work in
conflict and post-conflict settings globally [11, 30, 33]. A
study in Nepal revealed that roughly 19.0% of sex
workers reported having entered sex work directly be-
cause of subsistence needs attributed to local conflict
[30]. Our review of both the qualitative and the quanti-
tative literature pointed to the ways in which poverty,
diminished employment opportunities, difficulty meet-
ing subsistence needs, and challenges to sustainable
livelihoods in contexts of displacement influenced
engagement in sex work within conflict-affected set-
tings [3, 5, 11, 17, 23, 30, 32–41].
Within the context of family separation resulting from
armed conflict, increases in female-headed households
were common, and women often experienced reduced
access to traditional economic livelihoods, particularly in
the absence of male support [36, 37]. Stemming from
551 records identified
through database
searching
21 records identified
through other sources
156 duplicates removed
416 unique records
screened
331 records excluded based on title
screen; 37 records excluded based
on abstract screen
48 full-text records
assessed for eligibility
15 full-text records eliminated:
• 7 not focused on conflict/post-
conflict setting
• 4 not focused on sex work in
conflict/post conflict setting
• 2 were conference abstracts
• 1 did not stratify results of sex
workers
• 1 included only historical data
33 records included in review
Id
en
ti
fi
ca
ti
on
S
cr
ee
n
in
g
E
li
gi
b
il
it
y
In
cl
u
d
ed
Fig. 1 PRISMA
Ferguson et al. Conflict and Health (2017) 11:25 Page 4 of 20
T
a
b
le
2
C
h
ar
ac
te
ris
ti
cs
o
f
p
rim
ar
y
st
u
d
ie
s
p
er
ta
in
in
g
to
se
x
w
o
rk
an
d
H
IV
,S
TI
s,
an
d
SR
H
in
co
n
fli
ct
-a
ff
ec
te
d
se
tt
in
g
s
Re
fe
re
n
ce
Lo
ca
ti
o
n
D
es
ig
n
Po
p
u
la
ti
o
n
(N
)
St
ag
e
o
f
co
n
fli
ct
st
u
d
ie
d
Ke
y
Fi
n
d
in
g
s
Q
u
an
ti
ta
ti
ve
(1
3)
A
le
m
ay
eh
u
et
al
.
(2
01
5)
[3
2]
M
ek
el
le
C
it
y,
Et
h
io
p
ia
C
ro
ss
-s
ec
ti
o
n
al
SW
s
(N
=
25
0)
Po
st
-c
o
n
fli
ct
ST
Ih
is
to
ry
:1
7%
re
p
o
rt
ed
h
is
to
ry
o
f
an
ST
I,
g
o
n
o
rr
h
ea
(4
5.
8%
)
sy
p
h
ili
s
(4
1.
7%
),
an
d
ch
an
cr
o
id
(1
2.
5%
)
ST
It
es
tin
g
:9
.6
%
o
f
th
o
se
w
it
h
an
ST
I
re
p
o
rt
ed
h
av
in
g
so
u
g
h
t
tr
ea
tm
en
t
Re
p
ro
d
u
ct
iv
e
h
ea
lth
:2
7%
o
f
SW
s
re
p
o
rt
ed
a
h
is
to
ry
o
f
at
le
as
t
o
n
e
el
ec
ti
ve
ab
o
rt
io
n
,w
it
h
35
.3
%
o
f
th
es
e
w
o
m
en
re
p
o
rt
in
g
m
o
re
th
an
o
n
e
p
re
g
n
an
cy
te
rm
in
at
io
n
.
C
o
n
tr
a
ce
p
tiv
e
u
se
:6
9%
o
f
SW
s
ac
kn
o
w
le
d
g
ed
an
y
ty
p
e
o
f
co
n
tr
ac
ep
ti
ve
u
se
Vi
o
le
n
ce
:P
re
va
le
n
ce
o
f
se
xu
al
vi
o
le
n
ce
am
o
n
g
SW
s
=
75
.6
%
,c
o
rr
el
at
es
in
cl
u
d
ed
lo
w
er
ed
u
ca
ti
o
n
,s
ex
w
o
rk
d
u
ra
ti
o
n
,a
n
d
d
ru
g
u
se
.S
W
s
w
ith
lo
w
er
m
o
n
th
ly
in
co
m
e
w
er
e
th
e
m
o
st
lik
el
y
to
ex
p
er
ie
n
ce
se
xu
al
vi
o
le
n
ce
.
Bi
n
g
et
al
.(
20
08
)
[5
0]
A
n
g
o
la
C
ro
ss
-s
ec
ti
o
n
al
(B
eh
av
io
u
ra
l
su
rv
ei
lla
n
ce
st
u
d
y)
M
ili
ta
ry
p
er
so
n
n
el
(N
=
17
10
)
Po
st
-c
o
n
fli
ct
C
o
m
b
at
a
n
ts
a
s
se
x
b
u
ye
rs
:9
%
o
f
co
m
b
at
an
ts
re
p
o
rt
ed
h
av
in
g
se
x
w
ith
a
SW
in
p
as
t
12
m
o
n
th
s
C
o
n
do
m
u
se
:5
4.
2%
o
f
m
ili
ta
ry
p
er
so
n
n
el
re
p
o
rt
ed
u
si
n
g
a
co
n
d
o
m
at
la
st
se
x
w
it
h
a
SW
ST
Is
:C
o
m
b
at
an
ts
w
h
o
h
ad
ca
su
al
se
x
p
ar
tn
er
s
o
r
w
h
o
h
ad
se
x
w
it
h
a
SW
d
u
rin
g
th
e
p
as
t
ye
ar
w
er
e
si
g
n
ifi
ca
n
tl
y
m
o
re
lik
el
y
to
re
p
o
rt
ST
I
sy
m
p
to
m
s
th
an
th
o
se
w
it
h
o
u
t
su
ch
se
xu
al
p
ar
tn
er
s.
D
u
p
as
et
al
.
(2
01
2)
[4
3]
Ke
n
ya
Re
tr
o
sp
ec
ti
ve
st
u
d
y
-
SW
s
(N
=
24
8)
-
Se
lf-
em
p
lo
ye
d
en
tr
ep
re
n
eu
rs
(N
=
23
0)
-
Sh
o
p
ke
ep
er
s
(N
=
32
5)
A
ct
iv
e
an
d
p
o
st
-c
o
n
fli
ct
co
m
p
ar
is
o
n
In
flu
en
ce
o
f
p
o
lit
ic
a
l
vi
o
le
n
ce
o
n
u
n
p
ro
te
ct
ed
se
x:
SW
s
en
g
ag
ed
in
h
ig
h
er
ris
k
(u
n
p
ro
te
ct
ed
va
g
in
al
o
r
an
al
)
se
x
b
o
th
d
u
rin
g
an
d
af
te
r
th
e
p
o
st
-
el
ec
ti
o
n
cr
is
is
,t
o
m
ak
e
u
p
fo
r
in
co
m
e
sh
o
rt
fa
ll.
O
ve
ra
ll
le
ve
ls
o
f
h
ig
h
er
ris
k
se
x
d
ec
lin
ed
d
u
rin
g
th
e
cr
is
is
,b
u
t
w
o
m
en
re
sp
o
n
d
ed
to
th
e
n
eg
at
iv
e
in
co
m
e
sh
o
ck
b
y
si
g
n
ifi
ca
n
tl
y
in
cr
ea
si
n
g
th
e
am
o
u
n
t
o
f
u
n
p
ro
te
ct
ed
se
x
th
ey
h
ad
,c
o
n
d
it
io
n
al
o
n
b
ei
n
g
ab
le
to
fin
d
cl
ie
n
ts
.
Er
ic
ks
o
n
et
al
.
(2
01
5)
[3
1]
G
u
lu
,U
g
an
d
a
C
ro
ss
-s
ec
ti
o
n
al
SW
s
(N
=
40
0)
Po
st
-c
o
n
fli
ct
H
IV
/S
TI
p
re
va
le
n
ce
:2
2.
3%
SW
s
re
p
o
rt
ed
H
IV
in
fe
ct
io
n
an
d
40
.3
%
re
p
o
rt
ed
ST
Is
C
o
n
tr
a
ce
p
tiv
e
u
se
:4
5.
0%
o
f
SW
s
u
se
d
m
al
e
co
n
d
o
m
s
an
d
n
o
n
-b
ar
rie
r
fa
m
ily
p
la
n
n
in
g
m
et
h
o
d
s.
Po
lic
in
g:
H
av
in
g
to
ru
sh
se
xu
al
n
eg
o
ti
at
io
n
s
o
w
in
g
to
p
o
lic
e
p
re
se
n
ce
w
as
n
eg
at
iv
el
y
as
so
ci
at
ed
w
it
h
d
u
al
co
n
tr
ac
ep
ti
ve
u
se
(A
O
R
0.
65
,9
5%
C
I
0.
42
–
1.
00
;P
=
0.
05
0)
.
H
IV
te
st
in
g
:D
u
al
co
n
tr
ac
ep
ti
ve
u
se
w
as
p
o
si
ti
ve
ly
as
so
ci
at
ed
w
it
h
H
IV
te
st
in
g
(A
O
R
5.
22
,9
5%
C
I1
.7
5–
15
.5
7;
P
=
0.
00
3)
,s
u
g
g
es
ti
n
g
th
e
p
o
te
n
ti
al
im
p
o
rt
an
ce
o
f
b
et
te
r
in
te
g
ra
ti
o
n
o
f
H
IV
/S
RH
se
rv
ic
es
.
G
o
ld
en
b
er
g
et
al
.
(2
01
5)
[1
1]
G
u
lu
,U
g
an
d
a
C
ro
ss
-s
ec
ti
o
n
al
SW
s
(N
=
40
0)
Po
st
-c
o
n
fli
ct
H
IV
in
fe
ct
io
n
:3
3.
75
%
o
f
SW
s
w
er
e
H
IV
-s
er
o
p
o
si
ti
ve
(c
o
m
p
ar
ed
to
8.
51
%
o
f
w
o
m
en
o
f
re
p
ro
d
u
ct
iv
e
ag
e
in
g
en
er
al
p
o
p
);
o
f
w
h
o
m
33
.3
%
w
er
e
n
ew
/
p
re
vi
o
u
sl
y
u
n
d
ia
g
n
o
se
d
H
IV
in
fe
ct
io
n
s.
A
b
d
u
ct
io
n
b
y
re
be
ls
:W
ar
-r
el
at
ed
ab
d
u
ct
io
n
w
as
as
so
ci
at
ed
w
/H
IV
(A
O
R:
1.
62
,9
5%
C
I:
1.
00
–
2.
63
).
C
rim
in
a
liz
a
tio
n
:I
n
ca
rc
er
at
io
n
(A
O
R:
1.
93
,9
5%
C
I:
1.
17
–
3.
20
)
as
so
ci
at
ed
w
/
H
IV
Ferguson et al. Conflict and Health (2017) 11:25 Page 5 of 20
T
a
b
le
2
C
h
ar
ac
te
ris
ti
cs
o
f
p
rim
ar
y
st
u
d
ie
s
p
er
ta
in
in
g
to
se
x
w
o
rk
an
d
H
IV
,S
TI
s,
an
d
SR
H
in
co
n
fli
ct
-a
ff
ec
te
d
se
tt
in
g
s
(C
o
n
tin
u
ed
)
Re
fe
re
n
ce
Lo
ca
ti
o
n
D
es
ig
n
Po
p
u
la
ti
o
n
(N
)
St
ag
e
o
f
co
n
fli
ct
st
u
d
ie
d
Ke
y
Fi
n
d
in
g
s
H
ar
ris
o
n
et
al
.
(2
00
9)
[4
5]
O
ru
ch
in
g
a
an
d
N
ak
iv
al
e
re
fu
g
ee
se
tt
le
m
en
ts
,U
g
an
d
a
C
ro
ss
-
se
ct
io
n
al
(S
ta
n
d
ar
d
is
ed
b
eh
av
io
u
ra
l
su
rv
ei
lla
n
ce
su
rv
ey
(B
SS
))
-
Se
tt
le
m
en
t
re
fu
g
ee
s
w
h
o
so
ld
se
x
in
la
st
12
m
o
n
th
s
(N
=
93
)
-
U
g
an
d
an
s
in
su
rr
o
u
n
d
in
g
se
tt
le
m
en
t
ar
ea
w
h
o
so
ld
se
x
in
la
st
12
m
o
n
th
s
(N
=
47
)
Po
st
-c
o
n
fli
ct
Se
x
w
o
rk
fo
llo
w
in
g
d
is
p
la
ce
m
en
t:
M
o
re
re
fu
g
ee
s
th
an
n
at
io
n
al
s
re
p
o
rt
ed
ex
ch
an
g
in
g
se
x
fo
r
m
o
n
ey
,d
ru
g
s
o
r
o
th
er
g
o
o
d
s
(1
0%
ve
rs
u
s
6%
;
p
<
0.
01
),
w
h
ic
h
m
o
st
ly
o
cc
u
rr
ed
p
o
st
-d
is
p
la
ce
m
en
t.
Se
x
w
o
rk
en
g
ag
em
en
t
h
ig
h
er
in
th
e
re
fu
g
ee
p
o
p
u
la
tio
n
vs
.U
g
an
d
an
n
at
io
n
al
s
(4
.7
%
vs
.2
%
).
C
o
n
do
m
u
se
:C
o
n
d
o
m
u
se
w
as
lo
w
in
b
o
th
p
o
p
u
la
ti
o
n
s,
b
u
t
lo
w
er
am
o
n
g
re
fu
g
ee
s.
C
o
n
d
o
m
u
se
at
la
st
se
x
w
it
h
al
l
ty
p
es
o
f
p
ar
tn
er
s
(n
o
n
-r
eg
u
la
r,
p
ai
d
,a
n
d
h
ig
h
er
ris
k)
fo
u
r-
ti
m
es
h
ig
h
er
am
o
n
g
th
e
n
at
io
n
al
s
th
an
re
fu
-
g
ee
s,
b
u
t
co
n
fid
en
ce
in
te
rv
al
s
o
ve
rla
p
p
ed
.
Se
xu
a
lv
io
le
n
ce
:P
er
ce
n
ta
g
e
o
f
w
o
m
en
ag
ed
15
–
59
fo
rc
ed
to
h
av
e
se
x
in
th
e
p
as
t
ye
ar
w
as
ro
u
g
h
ly
th
e
sa
m
e
fo
r
re
fu
g
ee
s
(1
.3
%
)
as
n
at
io
n
al
s
(1
.2
%
).
Kr
iit
m
aa
et
al
.
(2
01
0)
[5
4]
H
ar
g
ei
sa
,S
o
m
al
ila
n
d
,
So
m
al
ia
C
ro
ss
se
ct
io
n
al
(In
te
g
ra
te
d
b
io
-b
eh
av
io
u
ra
ls
u
rv
ei
lla
n
ce
(IB
BS
))
SW
s
(N
=
23
7)
Po
st
-c
o
n
fli
ct
H
IV
in
fe
ct
io
n
:H
et
er
o
se
xu
al
co
m
m
er
ci
al
se
x
su
g
g
es
te
d
as
d
o
m
in
an
t
m
o
d
e
o
f
H
IV
tr
an
sm
is
si
o
n
C
o
n
do
m
u
se
a
n
d
a
cc
es
s:
24
.0
%
SW
s
re
p
o
rt
ed
u
si
n
g
a
co
n
d
o
m
at
la
st
SW
tr
an
sa
ct
io
n
an
d
o
n
ly
4.
3%
re
p
o
rt
ed
co
n
si
st
en
t
co
n
d
o
m
u
se
w
it
h
cl
ie
n
ts
in
th
e
p
as
t
m
o
n
th
.O
f
th
e
24
.0
%
w
h
o
d
id
u
se
a
co
n
d
o
m
at
la
st
se
x
w
it
h
a
cl
ie
n
t,
80
.5
%
sa
id
it
w
as
su
g
g
es
te
d
b
y
th
e
cl
ie
n
t.
29
.5
%
d
id
n
’t
u
se
co
n
d
o
m
s
w
it
h
cl
ie
n
ts
d
u
e
to
n
o
t
kn
o
w
in
g
w
h
er
e
to
o
b
ta
in
co
n
d
o
m
s.
A
lm
o
st
n
o
n
e
(0
.4
%
)
re
ce
iv
ed
co
n
d
o
m
s
th
ro
u
g
h
a
cl
in
ic
o
r
o
u
tr
ea
ch
in
th
e
p
as
t
ye
ar
.
H
IV
te
st
in
g
:O
n
ly
2.
6%
SW
s
kn
ew
w
h
er
e
to
g
o
fo
r
a
co
n
fid
en
ti
al
H
IV
te
st
.
4%
re
p
o
rt
ed
ev
er
h
av
in
g
h
ad
an
H
IV
te
st
,a
n
d
n
o
n
e
o
f
th
em
re
ce
iv
ed
th
ei
r
te
st
re
su
lt
s.
H
IV
p
re
ve
n
tio
n
:6
.9
%
SW
s
co
rr
ec
tl
y
an
sw
er
ed
al
l
5
q
u
es
ti
o
n
s
o
n
H
IV
fa
ct
u
al
kn
o
w
le
d
g
e;
o
n
ly
38
.4
%
h
ad
ev
er
h
ea
rd
o
f
an
ST
I.
La
rs
en
et
al
.
(2
00
4)
[3
6]
Si
er
ra
Le
o
n
e
Pr
e-
p
o
st
te
st
in
te
rv
en
ti
o
n
-
SW
s
(N
=
20
2)
-
M
ili
ta
ry
(N
=
20
5)
Po
st
-c
o
n
fli
ct
H
IV
kn
o
w
le
d
g
e:
O
n
ly
8.
5%
SW
s
an
d
22
.8
%
m
ili
ta
ry
kn
ew
>
3
m
o
d
es
o
f
H
IV
tr
an
sm
is
si
o
n
C
o
n
do
m
kn
o
w
le
dg
e/
a
cc
es
s:
14
.9
%
o
f
SW
s
an
d
12
.4
%
o
f
m
ili
ta
ry
kn
ew
n
o
so
u
rc
es
to
p
u
rc
h
as
e
co
n
d
o
m
s
In
te
rn
at
io
n
al
O
ff
ic
e
o
f
M
ig
ra
ti
o
n
(2
00
8)
[3
5]
H
ar
g
ei
sa
,S
o
m
al
ia
C
ro
ss
-s
ec
ti
o
n
al
(IB
BS
)
SW
s
(N
=
21
9)
A
ct
iv
e
co
n
fli
ct
H
IV
kn
o
w
le
d
g
e:
N
o
SW
s
kn
ew
th
ei
r
H
IV
st
at
u
s,
93
%
SW
s
la
ck
ed
co
rr
ec
t
H
IV
p
re
ve
n
ti
o
n
kn
o
w
le
d
g
e.
C
o
n
do
m
u
se
:2
8%
SW
s
h
ad
n
ev
er
u
se
d
a
m
al
e
co
n
d
o
m
M
ig
ra
tio
n
:6
9%
SW
s
w
er
e
m
ig
ra
n
ts
M
u
ld
o
o
n
et
al
.
(2
01
5)
[1
4]
G
u
lu
,U
g
an
d
a
C
ro
ss
-s
ec
ti
o
n
al
SW
s
(N
=
40
0)
Po
st
-c
o
n
fli
ct
H
IV
se
ro
pr
ev
a
la
n
ce
:3
3.
8%
SW
d
em
o
g
ra
p
h
ic
s:
Sa
m
p
le
w
as
g
en
er
al
ly
yo
u
n
g
,t
h
e
m
aj
o
rit
y
b
et
w
ee
n
th
e
ag
es
o
f
19
–
25
yr
s.
,m
an
y
w
it
h
d
ep
en
d
en
t
ch
ild
re
n
.6
5%
o
f
SW
s
h
ad
le
ss
th
an
p
rim
ar
y
sc
h
o
o
l
ed
u
ca
ti
o
n
Vi
o
le
n
ce
:4
9.
0%
o
f
SW
s
re
p
o
rt
ed
ex
tr
em
e
p
h
ys
ic
al
an
d
/o
r
se
xu
al
w
o
rk
p
la
ce
vi
o
le
n
ce
in
th
e
p
re
vi
o
u
s
si
x
m
o
n
th
s,
in
cl
u
d
in
g
p
h
ys
ic
al
as
sa
u
lt
,r
ap
e,
an
d
g
an
g
ra
p
e.
A
m
o
n
g
19
6
SW
s
w
h
o
re
p
o
rt
ed
cl
ie
n
t
vi
o
le
n
ce
,t
h
e
m
o
st
co
m
m
o
n
fo
rm
s
in
cl
u
d
ed
b
ei
n
g
p
h
ys
ic
al
ly
as
sa
u
lt
ed
(5
8.
7%
),
ra
p
ed
(3
8.
3%
),
th
e
cl
ie
n
t
at
te
m
p
ti
n
g
se
xu
al
as
sa
u
lt
(1
8.
4%
),
an
d
b
ei
n
g
g
an
g
ra
p
ed
(1
5.
8%
).
C
o
n
do
m
u
se
:8
4.
0%
SW
s
re
p
o
rt
ed
in
co
n
si
st
en
t
co
n
d
o
m
u
se
w
it
h
re
g
u
la
r
o
r
o
n
e-
ti
m
e
cl
ie
n
ts
.
Po
lic
in
g:
Ru
sh
in
g
n
eg
o
ti
at
io
n
s
d
u
e
to
p
o
lic
e
p
re
se
n
ce
co
n
tr
ib
u
te
d
to
cl
ie
n
t
vi
o
le
n
ce
(A
O
R:
1.
61
,9
5%
C
I:
1.
03
–
2.
52
).
H
ig
h
lig
h
ts
n
eg
at
iv
e
co
n
se
q
u
en
ce
s
o
f
p
o
lic
in
g
p
ra
ct
ic
es
fo
r
co
n
fli
ct
-a
ff
ec
te
d
SW
s.
Ferguson et al. Conflict and Health (2017) 11:25 Page 6 of 20
T
a
b
le
2
C
h
ar
ac
te
ris
ti
cs
o
f
p
rim
ar
y
st
u
d
ie
s
p
er
ta
in
in
g
to
se
x
w
o
rk
an
d
H
IV
,S
TI
s,
an
d
SR
H
in
co
n
fli
ct
-a
ff
ec
te
d
se
tt
in
g
s
(C
o
n
tin
u
ed
)
Re
fe
re
n
ce
Lo
ca
ti
o
n
D
es
ig
n
Po
p
u
la
ti
o
n
(N
)
St
ag
e
o
f
co
n
fli
ct
st
u
d
ie
d
Ke
y
Fi
n
d
in
g
s
N
tu
m
b
an
zo
n
d
o
et
al
.(
20
07
)
[4
4]
Ki
n
sh
as
a,
D
em
o
cr
at
ic
Re
p
u
b
lic
o
f
th
e
C
o
n
g
o
(D
RC
)
C
ro
ss
-s
ec
ti
o
n
al
SW
s
(N
=
13
6)
A
ct
iv
e
co
n
fli
ct
Se
xu
a
ld
ec
is
io
n
m
a
ki
n
g:
96
.3
%
SW
s
fe
lt
th
ey
w
er
e
ab
le
to
n
eg
o
ti
at
e
sa
fe
r
se
x
w
it
h
cl
ie
n
ts
.
C
o
n
do
m
u
se
:8
1.
6%
SW
s
al
w
ay
s
u
se
d
a
co
n
d
o
m
w
it
h
cl
ie
n
ts
,b
u
t
26
.5
%
re
p
o
rt
ed
ch
ar
g
in
g
ex
tr
a
fo
r
u
n
p
ro
te
ct
ed
se
x
w
it
h
cl
ie
n
ts
u
p
o
n
re
q
u
es
t.
U
n
p
ro
te
ct
ed
se
x
fo
r
m
o
re
m
o
n
ey
:S
W
s
w
h
o
en
g
ag
ed
in
u
n
p
ro
te
ct
ed
se
x
fo
r
m
o
re
m
o
n
ey
w
er
e
si
g
n
ifi
ca
n
tl
y
m
o
re
lik
el
y
to
liv
e
o
r
w
o
rk
at
n
o
n
-
…
Journal of
Preventive Medicine
& Public Health
298 Copyright © 2014 The Korean Society for Preventive Medicine
J Prev Med Public Health 2014;47:298-308 • http://dx.doi.org/10.3961/jpmph.14.029
Public Participation in the Process of Local Public Health
Policy, Using Policy Network Analysis
Yukyung Park1, Chang-yup Kim1, Myoung Soon You2, Kun Sei Lee3, Eunyoung Park4
1Department of Preventive Medicine, Graduate School of Public Health, Seoul National University, Seoul; 2Graduate School of Public Health, Seoul
National University, Seoul; 3Department of Preventive Medicine, Konkuk University School of Medicine, Seoul; 4Seoul Metropolitan Government
Public Health Policy Institute, Seoul, Korea
Original Article
Objectives: To assess the current public participation in-local health policy and its implications through the analysis of policy net-
works in health center programs.
Methods: We examined the decision-making process in sub-health center installations and the implementation process in metabolic
syndrome management program cases in two districts (‘gu’s) of Seoul. Participants of the policy network were selected by the snow-
balling method and completed self-administered questionnaires. Actors, the interactions among actors, and the characteristics of the
network were analyzed by Netminer.
Results: The results showed that the public is not yet actively participating in the local public health policy processes of decision-
making and implementation. In the decision-making process, most of the network actors were in the public sector, while the private
sector was a minor actor and participated in only a limited number of issues after the major decisions were made. In the implementa-
tion process, the program was led by the health center, while other actors participated passively.
Conclusions: Public participation in Korean public health policy is not yet well activated. Preliminary discussions with various stake-
holders, including civil society, are needed before making important local public health policy decisions. In addition, efforts to include
local institutions and residents in the implementation process with the public officials are necessary to improve the situation.
Key words: Public participation, Policy network, Social network analysis, Local public health policy, Policy process
Received: July 1, 2014 Accepted: September 22, 2014
Corresponding author: Chang-yup Kim, MD, PhD
559 Gwanak-ro, Gwanak-gu, Seoul 151-015, Korea
Tel: +82-2-880-2722, Fax: +82-2-762-9105
E-mail: [email protected]
This is an Open Access article distributed under the terms of the Creative Commons
Attribution Non-Commercial License (http://creativecommons.org/licenses/by-
nc/3.0/) which permits unrestricted non-commercial use, distribution, and repro-
duction in any medium, provided the original work is properly cited.
INTRODUCTION
Public policies have direct and indirect effects in the area and
population of their jurisdiction in a democratic political system,
pISSN 1975-8375 eISSN 2233-4521
and citizens should be able to participate freely in the political
process to voice their demands and preferences [1,2]. There are
two aspects of the recent emphasis on participation in the
public policy process worthy of review. One is the value aspect,
in which participation in a process that can influence one’s own
life is a fundamental right, and the other is the instrumental as-
pect, which includes the quality of decision making and im-
provement in policy compliance from a policy-goal achieve-
ment perspective. Participation has many levels and is difficult
to illustrate within a simple framework. More narrowly speak-
ing, participation in the policy-making process by the general
public, not public officials, can be defined as ordinary citizens
sharing the authority and the responsibility, that were exclusive
http://crossmark.crossref.org/dialog/?doi=10.3961/jpmph.14.029&domain=pdf&date_stamp=2014-12-04
299
Public Participation in Health Policy Journal of
Preventive Medicine
& Public Health
298 Copyright © 2014 The Korean Society for Preventive Medicine
to the government in the past, toward the establishment of a
cooperative relationship in the development and implementa-
tion of healthcare policies [3-5].
The participation of citizens in public health policies is impor-
tant. Beyond patient-doctor relationships and individual ac-
tions, it is a well-known fact that social determinants based on
systems and policies have a considerable influence on health.
In other words, people have the right to participate in all pro-
cesses related to their individual health. In particular, the citi-
zens’ desire to participate in health policies have been elevated
as many health policy-related problems, including health re-
sources allocation, the underprivileged, and interests between
classes, have surfaced [6]. In addition, for Korean society, the
public sector, including the Korean Health Insurance Corpora-
tion, the Korean Health Insurance Review and Assessment Ser-
vice, public health citizen groups, and the private sector have
continuously engaged in efforts for many years to establish a
forum for hearings and discussions on policies involving citizen
participation. However, how much is actually being done rela-
tive to the heightened awareness is still in question, and empir-
ical studies on the subject are lacking.
Previous studies on citizen participation in the health policy
process include studies on local healthcare planning and deci-
sion-making processes for a fluoride in tap water project [7-9],
and, in terms of enforcement, there have been studies on par-
ticipation patterns and influencing factors related to public
health promotion programs for public health centers [10,11].
However, in reality, despite the policy process involving complex
interactions of formal and informal relationships between vari-
ous participants, existing studies are limited to one-dimensional
examinations centered on literature reviews. Although there
have been attempts to address these shortcomings through
qualitative studies, including interviews [8,9], such efforts were
not enough to capture the overall aspects of the policy process
and the shape of the general public’s participation within it.
However, the policy-network analysis method has the advan-
tages of visualization and quantification, which allow intuitive
understanding of participants in the policy process and their in-
teractions.
The primary objective of this study was to determine the
state of citizen participation that is taking place in public health
policy processes in South Korea. In particular, the focus was on
local level, not the central government level, policy process; a
local community represents the actual field where people are
affected by endless encounters with problems and resolutions,
including health issues [12]. In terms of examinations of local
level public health policies using policy-network analysis, no
other studies, except one by Paik and Kim [13], were found.
Even that study was on the analysis of project structure and ex-
ploration of development directions and did not cover public
participation. Therefore, the present study aimed to identify
the pattern of participation in both the public and private sec-
tors by using a policy-network analysis at the community level,
which is closely tied to the daily routines of residents, the actual
subjects of healthcare, and thereby explored the state of citizen
participation and its potential.
METHODS
Study Subjects
To study the network for community health policy processes,
agenda setting, and decision-making stages, the process of es-
tablishing an urban sub-health center was examined; for study-
ing the policy implementation stage, a metabolic syndrome
management program was examined. The purpose of estab-
lishing the urban sub-health center was to provide a healthcare
safety net and guarantee healthcare access for a vulnerable
population. The function of the center was not simply diagno-
sis and treatment, but also health improvement and health
problem prevention and management. Accordingly, the opin-
ions of the local residents were necessary to project planning,
implementation, and evaluation. Mutual understanding of the
purpose of the sub-health center and the scope of the project
was important, and it was expected that cooperation and com-
munication between the public and private sectors were nec-
essary to the implementation of the project plan. Moreover,
the evaluation criteria for the establishment plan required
community participation and association planning.
The goal of the metabolic syndrome management program
extends beyond those who are admitted to the health centers
to all community residents for continued early detection and
management, and the relationship to other community re-
sources was essential to the program. Therefore, both cases
were suitable for examining how policy networks operate at
the decision-making and implementation stages. At the time
of this study (2012), four districts that had completed the es-
tablishment of urban sub-health centers within Seoul, the op-
erational status of the metabolic syndrome management pro-
grams, and survey accessibility were considered. This resulted
in the final selection of two districts, which included four poli-
Yukyung Park, et al.
300
cy-networks, consisting of establishment of an urban sub-
health center to examine the policy decision processes and a
metabolic syndrome management program to examine the
policy implementation process from each of the two districts
within Seoul, for the survey.
The decision-making process for the establishment of the
center, which covered the agenda setting and decision-mak-
ing processes, were chosen for study; this was between 2008
and 2009 for district A and between 2009 and 2010 for district
B. For the metabolic syndrome management program, it cov-
ered past one year from the survey. The survey was conducted
in July and August 2012. The policy-network analysis consisted
of examining the interactions and relationship structures of
administrators involved in the policy promotion process in the
studied cases. The analysis was at the organization level; study
participants included all agencies, groups, or organizations
(collectively referred to as “agencies” hereafter) from both the
public and private sectors that participated or were still partic-
ipating in each of the policies under study. However, to better
suit the study topic, these were limited to agencies under the
jurisdiction of respective districts and, if there were no special
reasons for inclusion, networks inside of the health center and
the district office were excluded. The three elements of policy-
network examined were the composition and characteristics
of study participants, interactions and relationships between
the participants, and the structure of the whole network. The
proportion of participation by the public and private sectors
including those individuals or organizations playing a central
role were also identified.
Survey Contents and Procedures
For the policy-network analysis, the focus was on egocentric
network data collection; therefore, data used in previous policy-
network studies were referenced, and a survey that fit the study
objectives and cases was constructed [13]. The survey was eval-
uated through a pilot study and internal meetings of research-
ers; following these actions, it was distributed to agency repre-
sentatives or workers responsible for case policies from the
agencies identified as participants. The survey consisted of
three sections: 1) network participants: the general classifica-
tion under which the agency belonged, awareness of policy
participation, and agencies associated with the policy process;
2) network characteristics: content of exchange between asso-
ciated agencies (information, resources, and route of exchange),
strength, reliability, frequency, and nature (cooperation or con-
flict); and 3) network formation: reasons for participating in the
policy, reasons for exchange between associated agencies, and
agencies with influence during the policy participation process.
The survey was conducted via snowball sampling. First, the
most readily accessible person in charge of each of the two
policy cases from each district was surveyed as a representative
of the corresponding health center. A list of agencies that had
primary connections to the health center was obtained, and
these agencies were surveyed. Then the agencies with connec-
tions to agencies on the first list were identified. This process
was repeated until no new agencies were identified [14]. The
survey was emailed or hand-delivered to all participants and
the responses were returned to the researcher. Any unclear re-
sponses were immediately reconfirmed or through follow up
telephone calls.
Analysis Methods
For the general characteristics and awareness of the agen-
cies, frequency analysis, t-tests, and Wilcoxon rank-sum tests
were performed, and for policy-network analysis, social net-
work analysis was used. A social network analysis consists of vi-
sualization and analysis of structural properties; visualization,
which is considered to have an advantage over other methods
of analysis, intuitively displays the connection between the ac-
tivity performers that exists as numeric data, which may be dif-
ficult to understand [15]. The indices used in network analysis
were the network’s size and density, degree, closeness, and be-
tweenness centrality and centralization. In network analysis,
the goal of central structure analysis is to identify which activity
performers are the most important among all activity perform-
ers and to determine the degree of centrality, that is to what
degree the network structure is centralized to the activity per-
formers identified as most important. Three types of centrality
values, which determine the importance of each activity per-
former, were analyzed. Degree centrality measures the size of
direct influence; closeness centrality measures the immediacy,
which indicates how quickly information is sent and received
between activity performers; and betweenness centrality mea-
sures the influence that is generated during the information or
influence “delivery process,” in other words, the level of control
on the flow of information or resources.
A similar index, centralization, indicates the central concen-
tration of the entire network, rather than showing levels of in-
dividual activity performers. In addition, directionality should
be considered in looking at the relationships between activity
301
Public Participation in Health Policy
performers. Directionality includes “in-degree,” which refers to
the activity performer acting as the reference for the flow of
information, resources receiving such information, or resources
from another activity performer, and “out-degree,” which refers
to the referenced activity performer sending these to other ac-
tivity performers. Therefore, in-degree looks at the level of influ-
ence possessed by the activity performer and out-degree is in-
terpreted by the activity performer’s sociability or the struc-
ture’s expandability [16]. The program used for network analysis
was Netminer 4.0, and for other analyses, Stata/SE version 12.0
(Stata Corp., College Station, TX, USA) was used.
RESULTS
The organizations ultimately selected for the analysis were 8
and 9 agencies from districts A and B, respectively, for the ur-
ban sub-health center establishment process, and 30 and 32
agencies from districts A and B, respectively, for the metabolic
syndrome management program. In the process of the urban
sub-health center’s establishment, the participating agencies
were 6 out of 8 (75%) from district A and 6 out of 9 (66.7%)
from district B. There was a greater participation rate from the
public sector with a pattern of involvement by few private
agencies centered on health centers and the district head of-
fice. As for metabolic syndrome management program, the dis-
tinction between public and private sectors was not particularly
meaningful, as most of the interacting agencies were generat-
ed from interactions by the health centers from conducting the
“outreach health consultation”. In terms of the level of aware-
ness by the participating agencies with respect to the influence
of the general public on community health policy process, for
each case and stage, distributions of 4.6 points (minimum) to
6.2 points (maximum) were seen. There were no significant dif-
ferences observed the comparisons of public sector to private
sector and decision process to implementation process.
Policy Decision Network and Citizen Participa-
tion: The Establishment of the Urban Sub-health
Center Process
The eight agencies from district A identified as participants
in the establishment of the urban sub-health center decision
process were analyzed. The public sector included the depart-
ment in charge of the establishment of the sub-health center
process (hereinafter “health center”), the family welfare divi-
sion, the head of district from the district head office, and the
community center and its sub-department in charge of neigh-
borhood management programs. The private sector consisted
of the citizens’ community committee and a functional organi-
zation (a medical association).
Figure 1 shows the schematic diagram of the network of the
policy-making process for establishment of the urban sub-
health center in district A. The shape of the nodes represents
whether the participating agencies belonged to the public or
private sector, the thickness of the arrows indicates the strength
of the relationship, and the shape of the arrows indicate the
properties of the interaction.
Due to the geographical characteristics of district A, there
were complaints from residents in a section of the district that
access to the health center was inconvenient and that repairs
and improvements to the existing sub-health centers, based
on public health and welfare promises made by the district
head for “installation of regional sub-health centers”, had not
been completed. Therefore, the establishment of the urban
sub-health center was initiated, with the public health division
to be set at the center of the process. The urban sub-health
center was planned for the same location as an existing sub-
health center, by expanding the use of the building from one
to four floors. During this process, problems with relocation of
the youth cultural center and neighborhood management
programs’ offices, which were already operating at the planned
expansion site, were encountered. The residents utilizing the
programs opposed the relocation; this opposition was relayed
by the head of the neighborhood management program (also
a community autonomy board member). The community cen-
ter in charge and the corresponding district division engaged
in negotiations. As a result, the youth cultural center was relo-
cated and a decision was made to operate the neighborhood
management program in its original location with different
operating hours than the sub-health center.
Among the nine agencies participating in the establishment
of the urban sub-health center establishment decision process
from district B, the public sector consisted of the department
in charge of the entire sub-health center establishment pro-
cess (hereinafter “health center”) and the head of district, the
district council, district office (A), and the division in charge of
veterans’ organizations. The private sector consisted of the citi-
zens’ community committee and its board, along with two vet-
erans’ organizations (Figure 1).
In district B, the person who acted as the starting point and
played a decisive role in the establishment of the urban sub-
Yukyung Park, et al.
302
health center process was the head of district. The head of dis-
trict requested information from various district departments
about budget, land procurement, construction, and human re-
sources, and delegated the work to the head of health center
and the department in charge within the health center. Because
the district office and health center were sub-divisions of the
regional autonomous municipality, referred as district B, acting
with full acceptance of the will of and instructions from the
head of district can be understood. The health center frequently
attended board meetings, at the request of the district council,
to explain the establishment of the urban sub-health center
and its necessity, as well as to report on the process, thereby
forming a close relationship. The health center sent information
to the corresponding community center in the neighborhood
where the urban sub-health center was to be established, but
during the site selection process, conflicts arose with two veter-
ans’ organizations already situated at the site. The site selection
process required negotiations with the corresponding depart-
ment within the district office and the establishment of the
sub-health center experienced delays.
In both cases, there were no direct connections with health-
care functional organizations. In particular, medical associa-
tions did not participate in the actual decision-making process,
although it appears these groups participated in post-decision
discussion on cooperation. Although the mechanisms of public
and private sectors appear to be similar, the process in district B
was a more public-centric hierarchical structure, centered on
the health center, district office, and district council, than the
process in district A was.
The most basic indices used to examine policy-network char-
acteristics are size and density. In district A, density, which is
the relationship of possible connections to actual connections
within a network, was 32.1%, which represented 18 out of 56
possible connections. District B’s density was 23.6%, which rep-
resented 17 out of 72 possible connections. District B, com-
pared to district A, had a relatively larger network size, but den-
sity, indicative of the level of connection, was lower. In relation-
ship to the schematic diagram, the relationships in district B
were hierarchical rather than mutually horizontal. This can be
interpreted as a similar pattern of information and resources
flowing to each department.
The network centrality and centralization values from the
two districts are presented in Table 1. In terms of centrality and
centralization values from district A, the health center took the
highest positions for both in and out degree, appearing to have
the largest influence; particularly in the out-degree, which is
the aspect of providing information and resources that actually
drives the policy decision process, the health center had the
most active and important role. For centrality and centraliza-
tion values from district B, the two veterans’ organizations
Figure 1. Network of the policy-making process for establishment of the urban sub-health center. (A) District A and (B) district B.
A B
303
Public Participation in Health Policy
showed high in-degree values for connection centrality and
closeness centrality. The interpretation of this is that the veter-
ans’ organizations took a relatively high position in the power
relationship within the series of small networks surrounding
the issue of site selection and had fewer overall nodes. As the
health center showed the highest values for betweenness cen-
trality and all types of out-degree centrality, the results were
not much different from district A. In the network of the policy-
making process for establishment of the urban sub-health cen-
ter, district B, in comparison to district A, had relatively low in-
degree centralization, and out-degree centralization was rela-
tively low in connection centralization and relatively high in
closeness centralization. Unlike district A, which showed con-
nectivity strongly centered on health center, district B showed
more of a hierarchical relationship (head of district–district of-
fice–health center) and presence of connection networks sur-
rounding the veterans’ organizations, which may have weak-
ened the centralization tendencies. Despite this, it can be seen
from the out-degree closeness centralization value that health
center still played an important role.
In the evaluation of inter-departmental relationships, dis-
tricts A and B reported negative mutual exchanges of 18.8%
and 14.3%, respectively. The reasons given were that not all
departments shared the same interests and they were unable
to cooperate well; such evaluations came primarily from the
conflict during the site selection process.
Policy Implementation Network and Citizen Par-
ticipation: Metabolic Syndrome Management
Program Case
The metabolic syndrome management program in district A
was centered on the health center as a complete star shape. In
looking at the figure, the health center formed one-on-one as-
sociations with individual agencies and groups, which did not
continue on to further connections and only isolated associa-
tions were added (Figure 2).
District B’s schematic diagram of metabolic syndrome man-
agement program showed an overall star shape, but the pres-
ence of some links is seen between the interacting agencies.
One was the link that originated from community center, which
played the role of introducing the program and making con-
nections to nearby agencies and other functional groups with-
in its jurisdiction, including the youth leaders council, defense
council, sub-district council, community credit co-op, and oth-
ers. Another link was centered around neighborhood coalition,
care center, and self-support center; of these, neighborhood
coalition, organized approximately ten years ago as a civil ac-
tivity group, was at the center. The health center attempted to
expand this link to approximately 10 other civic organizations.
Besides these, a link had formed between high school D and
primary school A, with the schools in close geographical prox-
imity to each other (Figure 2).
The network density of district A’s metabolic syndrome man-
agement program implementation process was 6.4%, repre-
senting 56 connections out of 870 possible connections, which,
when compared to the network of policy-making process for
establishment of urban sub-health center, was very low. The
network density of district B was 7.1%, representing 70 connec-
Table 1. Centrality and centralization score of the network of
establishment of the urban sub-health center
In-
degree
Out-
degree
In-
closeness
Out-
closeness
Node-
between-
ness
District A
Centralization 52.4% 71.4% 51.9% 59.7% 53.1%
Centrality
Health center 0.71 0.86 0.73 0.88 0.57
Community center 0.43 0.57 0.57 0.70 0.12
Citizens community
committee
0.43 0.29 0.57 0.58 0.15
Family welfare
division
0.29 0.14 0.51 0.50 0.00
Administration
management
division
0.29 0.29 0.51 0.54 0.00
Head of district 0.14 0.14 0.43 0.50 0.00
Culture program
section
0.14 0.29 0.37 0.50 0.01
Medical association 0.14 0.00 0.50 0.00 0.00
District B
Centralization 17.9% 50.0% 36.7% 70.9% 37.3%
Centrality
Veterans’
organization A
0.38 0.25 0.47 0.25 0.04
Veterans’
organization B
0.38 0.25 0.47 0.25 0.04
Health center 0.25 0.63 0.33 0.73 0.43
Head of district 0.25 0.25 0.29 0.50 0.18
Council of district 0.25 0.25 0.29 0.50 0.18
District office B 0.25 0.25 0.34 0.25 0.00
District office A 0.13 0.13 0.20 0.35 0.00
Citizens community
committee
0.13 0.13 0.20 0.35 0.00
Community center 0.13 0.00 0.28 0.00 0.00
Yukyung Park, et al.
304
tions out of 992 possible connections, which appeared slightly
higher than district A, but indicated almost no difference.
The centrality and centralization values from the networks of
the two districts are shown in Table 2. As can be surmised from
the schematic diagram, for all types of centrality from both dis-
tricts A and B, the health center appeared the highest, and in
particular, betweenness centrality for all types of agencies was
close to zero, except for the health center. This type of case in-
dicated that the network structure was very fragile and, if the
health center organization disappears, the network will experi-
ence a complete breakdown and will be difficult to maintain
further; even if the person in charge is replaced or changes in
resources for the central agency occur, the network still may
not function properly. In addition, considering the material and
immaterial resources needed for forming and maintaining the
network, this type can also be viewed as being highly ineffec-
tive. However, despite the fact that both districts showed the
same pattern of being heavily concentrated on the health cen-
ters, the differences between the two districts were seen in the
questions regarding network formation. Regarding the reasons
for participating in the metabolic syndrome management pro-
gram network in district A, 36% responded it was due to official
or unofficial requests and/or because of …
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Ethics
We can mention at least one example of how the violation of ethical standards can be prevented. Many organizations promote ethical self-regulation by creating moral codes to help direct their business activities
*DDB is used for the first three years
For example
The inbound logistics for William Instrument refer to purchase components from various electronic firms. During the purchase process William need to consider the quality and price of the components. In this case
4. A U.S. Supreme Court case known as Furman v. Georgia (1972) is a landmark case that involved Eighth Amendment’s ban of unusual and cruel punishment in death penalty cases (Furman v. Georgia (1972)
With covid coming into place
In my opinion
with
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The ability to view ourselves from an unbiased perspective allows us to critically assess our personal strengths and weaknesses. This is an important step in the process of finding the right resources for our personal learning style. Ego and pride can be
· By Day 1 of this week
While you must form your answers to the questions below from our assigned reading material
CliftonLarsonAllen LLP (2013)
5 The family dynamic is awkward at first since the most outgoing and straight forward person in the family in Linda
Urien
The most important benefit of my statistical analysis would be the accuracy with which I interpret the data. The greatest obstacle
From a similar but larger point of view
4 In order to get the entire family to come back for another session I would suggest coming in on a day the restaurant is not open
When seeking to identify a patient’s health condition
After viewing the you tube videos on prayer
Your paper must be at least two pages in length (not counting the title and reference pages)
The word assimilate is negative to me. I believe everyone should learn about a country that they are going to live in. It doesnt mean that they have to believe that everything in America is better than where they came from. It means that they care enough
Data collection
Single Subject Chris is a social worker in a geriatric case management program located in a midsize Northeastern town. She has an MSW and is part of a team of case managers that likes to continuously improve on its practice. The team is currently using an
I would start off with Linda on repeating her options for the child and going over what she is feeling with each option. I would want to find out what she is afraid of. I would avoid asking her any “why” questions because I want her to be in the here an
Summarize the advantages and disadvantages of using an Internet site as means of collecting data for psychological research (Comp 2.1) 25.0\% Summarization of the advantages and disadvantages of using an Internet site as means of collecting data for psych
Identify the type of research used in a chosen study
Compose a 1
Optics
effect relationship becomes more difficult—as the researcher cannot enact total control of another person even in an experimental environment. Social workers serve clients in highly complex real-world environments. Clients often implement recommended inte
I think knowing more about you will allow you to be able to choose the right resources
Be 4 pages in length
soft MB-920 dumps review and documentation and high-quality listing pdf MB-920 braindumps also recommended and approved by Microsoft experts. The practical test
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One thing you will need to do in college is learn how to find and use references. References support your ideas. College-level work must be supported by research. You are expected to do that for this paper. You will research
Elaborate on any potential confounds or ethical concerns while participating in the psychological study 20.0\% Elaboration on any potential confounds or ethical concerns while participating in the psychological study is missing. Elaboration on any potenti
3 The first thing I would do in the family’s first session is develop a genogram of the family to get an idea of all the individuals who play a major role in Linda’s life. After establishing where each member is in relation to the family
A Health in All Policies approach
Note: The requirements outlined below correspond to the grading criteria in the scoring guide. At a minimum
Chen
Read Connecting Communities and Complexity: A Case Study in Creating the Conditions for Transformational Change
Read Reflections on Cultural Humility
Read A Basic Guide to ABCD Community Organizing
Use the bolded black section and sub-section titles below to organize your paper. For each section
Losinski forwarded the article on a priority basis to Mary Scott
Losinksi wanted details on use of the ED at CGH. He asked the administrative resident