Salaam Afghanistan

Health and Ethnic Conflict.

My first visit to the Heart of Asia -- Reflections and Photos.

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Name:
Location: Mbarara, Uganda

Internist and Pediatrician with a passion for international health.

Tuesday, July 20, 2004

Project Overview

Our first official study site was in a district called Shakardara. Wait. How much have I told you about my study? I spent the first two weeks here designing the study and designing the training for the field team, but now that I think of it, I feel like maybe I haven't shared that much with you about that.

Okay. So first things first. Below find a brief overview of the study:

Where a Pregnant Woman Delivers in Afghanistan: Important Factors in the Decision-Making Process
 
Project Overview

A qualitative study relating to the decision-making process regarding place of delivery for pregnant women in Afghanistan.  This will be a pilot study, designed to provide initial guidance to interested parties and to inform further research.

Main Question(s)

What factors should NGOs and other organizations consider when designing culturally appropriate birthing services in Afghanistan?  What are some ways that NGOs and other organizations might increase demand for facility-based delivery in Afghanistan?

1a.       Among those families wherein women deliver in health facilities, what are the considerations that lead them to choose facility-based delivery?
2a.       Among those families wherein women do not deliver in health facilities and who have access to such facilities, why do they deliver at home?
2b.       Among those families wherein women do not deliver in health facilities and who have access to such facilities, what services and factors would be necessary in order for them to consider delivery in the facility?
 
Methods

Prepare FGD guide.

Develop questions ( 8 – 12 questions per FGD) based on preliminary guidance from knowledgeable individuals among REACH staff and in local NGOs.

Send the guiding questions to English-speaking REACH staff for review and revision.

Translate the guiding questions into Dari.

Send the guiding questions to Dari-speaking REACH staff for review and revision.

Field test the questions.  One site that is easily accessible is sufficient.

Revise the questions based on field test results.

Identify and train Dari-speaking moderators.

Identify two sites at which to conduct the qualitative research, one urban/semi-urban and one rural.

Identify and recruit participants (maximum 10 participants per group) for focus group discussions (FGDs) on-site in designated waiting areas at times when desired groups are generally available (determined through consultation with clinic/hospital staff): 

Research will be conducted using six FGDs per site, for a total of twelve FGDs. 
            
Each site will have two sets of FGDs – one set including members of families wherein women deliver in health facilities (HFs), and one set including members of families wherein women do not deliver in health facilities and who have access to such facilities.

Each of the two sets will be further divided into three distinct FGDs – one composed of women’s husbands, one composed of women’s mothers-in-law, and one composed of the women themselves.

See diagram below. 

                                                            --Husbands 

                                                          /
                   ----Deliver in HFs-------Mothers-in-law 
                 /                                       \   
                /                                          --Women 
RURAL  
                \                                          --Husbands
                  \                                       /
                    Do not deliver in HFs----Mothers-in-law 
                                                           \   
                                                             --Women    

                      
                                                            --Husbands 
                                                          /                  
                   ----Deliver in HFs-------Mothers-in-law                 
                 /                                       \   
                /                                          --Women                
URBAN                                                                  
                \                                          --Husbands
                  \                                       /                   
                   Do not deliver in HFs----Mothers-in-law                
                                                          \   
                                                             --Women   


Clarifications:

·         “families wherein women do/do not deliver in health facilities” should include families in which a woman has delivered a child within the past 18 months.

·         It is not necessary to limit the participants by requiring that the husbands, mothers-in-law, and women are all in the same family.  However, this information should be documented and noted. 

Conduct FGDs in Dari employing an Afghan moderator who has a similar profile to the participants in the group.  Men should be interviewed by a man, and women should be interviewed by a woman. 

The FGDs will include the moderator and a note-taker.  The note-taker should also be Afghan to minimize bias that may be introduced by the presence of the expatriate, and to allow for detailed note-taking in the event that participants express unwillingness to be tape-recorded.  Notes taken by a non-Dari speaker are limited to physical and interpersonal observation. 

The FGDs will be conducted over 2 days.  At least two and not more than four FGDs will be conducted on a given day.  Each FGD should last approximately one hour. 

Sunday –          FGDs with husbands of women who do/do not deliver in health facilities (1 morning, 1 afternoon)
Simulataneous FGDs with mothers-in-law of women who do/do not deliver in health facilities.

Monday –        FGDs with women who do/do not deliver in health facilities. (1 morning, 1 afternoon)

Transcribe the audio recordings of the FGDs, and translate the transcriptions from Dari into English.

Resources Required

Human resources:
·         2 project managers.
·         2 moderators—1 male and 1 female.
·         2 note-takers/transcribers/translators—1 male and 1 female.

Technical resources:
·         4 audio recorders.
·         15 audio cassettes, with at least 90 minutes per cassette.
·         Camera.
·         Batteries

Other resources:
·         Pens.
·         Notepads.
·         Tea/biscuits

Limitations

Afghanistan is a very heterogenous country.  Customs, beliefs, and needs will vary greatly across the country, depending on ethnicity and religion along with a range of other variables.  This is of particular importance in the rural areas, as variation between rural areas can be much greater than variation between urban areas.

For the most reliable results, FGDs should be conducted in an environment that provides the greatest degree of comfort possible for the participants.  Our FGDs will be conducted in the presence of female expatriates.  Foreign presence in the FGDs is likely to affect the results – common experience demonstrates that foreign presence stifles freedom of discussion among participants, and may also lead participants to answer as they believe they are “supposed to.”  It is not clear how the presence of a female expatriate in a group of male participants will affect the results; however, given the gender norms of Afghan society, it is reasonable to expect that the discussion will be impacted.

Our methods require two different translation and interpretation processes, one at the beginning to translate the guiding questions from English into Dari, and one at the conclusion of the study to translate the discussion transcriptions from Dari back into English.  It is well documented that translations decrease the reliability of the results.


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