Staff Publications

Staff Publications

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    'Staff publications' is the digital repository of Wageningen University & Research

    'Staff publications' contains references to publications authored by Wageningen University staff from 1976 onward.

    Publications authored by the staff of the Research Institutes are available from 1995 onwards.

    Full text documents are added when available. The database is updated daily and currently holds about 240,000 items, of which 72,000 in open access.

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    Understanding poverty-related diseases in Cameroon from a salutogenic perspective
    Makoge, Valerie - \ 2017
    Wageningen University. Promotor(en): M.A. Koelen, co-promotor(en): H. Maat; H.W. Vaandrager. - Wageningen : Wageningen University - ISBN 9789463434515 - 193
    armoede - kameroen - malaria - tyfus - acquired immune deficiency syndrome - hiv-infecties - cholera - tuberculose - diarree - gezondheidsgedrag - gezondheidsvoorzieningen - spanningen - poverty - cameroon - malaria - typhoid - acquired immune deficiency syndrome - hiv infections - cholera - tuberculosis - diarrhoea - health behaviour - health services - stresses

    Poverty-related diseases (PRDs) assume poverty as a determinant in catching disease and an obstacle for cure and recovery. In Cameroon, over 48 % of the population lives below the poverty line. This dissertation starts from the premise that the relation between poverty and disease is mediated by a person’s capacity to cope with the challenges posed by the natural and social environment. The central problem addressed is that in (inter)national health promotion, disease eradication is overemphasized whereas strengthening the capacity of people to cope with harsh conditions is disregarded. Research efforts show a similar division in emphasis, resulting in a limited understanding of the way people deal with health challenges in conditions of poverty. This dissertation is based on the salutogenic model of health that emphasizes the combined effects of (natural) disease conditions, mental conditions and social factors as determinants of health. This implies an emphasis on health as a positive strategy to deal with stressors and also an emphasis on the agency of people to respond to challenges that hamper their health and wellbeing. The study is carried out among two different groups of people in Cameroon. These are workers including dependants of workers of the Cameroon Development Corporation (CDC) and students from the universities of Buea and Yaoundé. The overall aim of this dissertation is to understand how conditions of poverty impact the health of people and how they manage these challenges. Specifically, the study aims to unravel the interlinkages between poverty and health by creating a deeper understanding of the social and material dynamics which enable people’s capacity to preserve health, anticipate health risks, and mitigate or recover from stressors such as PRDs. The main research question addressed is: What factors underlie the maintenance of good health and overcoming stressors in the face of PRDs in Cameroon?

    Different research methods were used to collect data. Interviews were carried out with respondents from both groups addressing PRDs, other stressors and coping strategies. General surveys were carried out to identify perceptions as well as health behaviour patterns across the two groups. Standardised surveys were carried out to measure individual factors such as sense of coherence, resilience, self-efficacy, subjective well-being and self-rated health. Results presented in different empirical chapters of the thesis each respond to a specific research question. In Chapters 2 and 3 are presented surveys with 272 students and 237 camp-dwellers respectively. Perceptions, attributed causes of, and responses towards PRDs are explored as well as motivations for given responses to health challenges. In chapter 4, a qualitative study with 21 camp-dwellers and 21 students is presented in which the dynamics of health-seeking behaviour is highlighted. In this chapter also, factors which are influential in seeking formal healthcare are indicated. Chapter 5 elaborates on what people experience as stressors and the mechanisms they put in place to cope with the stressors. In this chapter, not only is the diversity of stressors outlined for both groups, but also presented are the different identified coping mechanisms put in place by respondents. Chapter 6 which is the last empirical chapter presents coping with PRDs through an analysis of individual, demographic and environmental factors.

    Based on the studies carried out, this thesis concludes that the two groups investigated are very aware of what PRDs are and can differentiate them from common diseases. Major PRDs listed by the two groups of respondents were malaria, cholera and diarrhoea. This classification is different from what is considered major PRDs by (inter)national health bodies such as the World Health Organisation and the Ministry of Public Health in Cameroon. Also, organisations such as CDC and Universities, offer limited contributions towards better health for camp-dwellers and students respectively. This is experienced relative to the living conditions, quality of the healthcare system and poor work or study conditions. That notwithstanding, people play an active role in maintaining their health through diverse coping mechanisms. Coping was most strongly related to enabling individual factors such as sense of coherence and subjective health, perceptions of effective strategies to respond to diseases as well as social factors such as the meaningful activities in the social groups to which they belong. The results presented in this thesis are intended to contribute to sustainable and effective response strategies towards PRDs.

    Communicating with the chronically ill : effective self-management support in health care
    Mulder, B.C. - \ 2014
    Wageningen University. Promotor(en): Cees van Woerkum, co-promotor(en): Anne Marike Lokhorst; M. Bruin. - Wageningen : Wageningen University - ISBN 9789462571556 - 151
    chronische ziekten - gezondheidszorg - communicatie - zelfbeheer - patiënten - gezondheidsgedrag - hiv-infecties - diabetes type 2 - chronic diseases - health care - communication - self management - patients - health behaviour - hiv infections - type 2 diabetes

    Samenvatting

    Wereldwijd vormen chronische ziekten een enorme humanitaire en economische last. Op individueel niveau moet patiënten zelf leren omgaan met de gevolgen van hun chronische ziekte, een proces dat zelfmanagement wordt genoemd. Patiënten kunnen op veel verschillende manieren aan zelfmanagement doen, waarmee ze hun eigen gezondheid en welzijn beïnvloeden. Omdat chronisch zieke patiënten regelmatige zorggebruikers zijn, kan zelfmanagementondersteuning daarnaast helpen om kosten voor de gezondheidszorg te verminderen. Hoe interpersoonlijke communicatie tussen patiënten en zorgverleners daadwerkelijk zelfmanagement kan ondersteunen is een gebied dat nader onderzoek behoeft.

    In Hoofdstuk 1 wordt het onderzoek in dit proefschrift geïntroduceerd door de relaties tussen chronische ziekten, gezondheidsgedrag en gezondheidscommunicatie te bespreken. De wereldwijde stijging van chronische ziekten zoals hart- en vaatziekten, diabetes en SOA’s kan grotendeels worden toegeschreven aan gezondheidsgedrag zoals roken, lichamelijke inactiviteit, ongezonde voeding en onveilige geslachtsgemeenschap. Ondanks grote investeringen in interventies om gezond gedrag te bevorderen is het effect van deze interventies vaak beperkt en kunnen dit soort interventies naar verwachting niet het tij keren op populatieniveau. Daarom zullen steeds meer mensen een chronische ziekte krijgen, waarvoor zij behandeld zullen worden in de gezondheidszorg. Deze ontwikkeling heeft gevolgen voor de manier waarop met patiënten het beste gecommuniceerd kan worden over hun ziekte.

    Patiënten met een chronische ziekte moeten voor zichzelf zorgen, omdat hun ziekte niet kan worden genezen en omdat hun dagelijkse beslissingen de progressie van hun ziekte beïnvloeden. Patiënten moeten hun ziekte zelf managen. De regelmatige bezoeken van patiënten aan hun zorgverleners bieden een kans voor ondersteuning van deze zelfmanagement, omdat gezondheidsgedrag vaak al een regelmatig onderwerp van bespreking is. Daarnaast wijst onderzoek uit dat advies van zorgverleners en interpersoonlijke communicatie effectiever zijn dan massamediale communicatie en gemedieerde persoonlijke communicatie (bijv. via e-mail of telefoon).

    Echter, zelfmanagement kan op verschillende manieren worden gedefinieerd en overeenkomstig de verschillende definities kan ondersteuning van zelfmanagement diverse vormen aannemen. Een belangrijk verschil is dat sommige definities zelfmanagement beschrijven vanuit het perspectief van de patiënt, terwijl andere definities meer normatief zijn door te stellen wat patiënten moeten doen vanuit medisch oogpunt om progressie van de ziekte te voorkomen. In dit proefschrift wordt zelfmanagement fundamenteel gezien als een zaak van de patiënt en gericht op het behoud van welzijn. Patiënten doen dit door het managen van de medische kant, het omgaan met de functionele beperkingen als gevolg van de ziekte en tot slot het omgaan met de emotionele gevolgen ervan. Een algemeen doel van dit proefschrift is om een beter begrip te krijgen van hoe zelfmanagement effectief te ondersteunen is tijdens interpersoonlijke gezondheidscommunicatie, vanuit het perspectief van de patiënt.

    Vroege studies over zelfmanagement geven aan dat controle een centraal construct is in het verklaren van de effectiviteit van zelfmanagementondersteuning. Een gevoel van controle over de ziekte, of hoge eigen-effectiviteit met betrekking tot specifiek zelfmanagementgedrag, kunnen bijvoorbeeld gezondheid en welzijn van patiënten voorspellen, maar ook gezondheidsgedrag positief beïnvloeden. Daarom is het uitgangspunt van dit proefschrift om zelfmanagementondersteuning te zien als het ondersteunen van de daadwerkelijke en waargenomen controle van patiënten over hun ziekte. Het onderzoeken van patiënt-zorgverlenercommunicatie kan verdere conceptuele en praktische inzichten bieden omtrent hoe communicatie zelfmanagement kan ondersteunen. De specifieke doelstellingen van dit proefschrift zijn: a) om de controlefactoren te verkennen die kunnen bijdragen aan variatie in gezondheidsgedrag; b) om voorkeuren van patiënten te onderzoeken voor zorgverlenercommunicatie die uiteindelijk gericht is op ondersteuning van zelfmanagement, en hoe zorgverleners kunnen voldoen aan deze voorkeuren; en c) te onderzoeken wat zorgverleners verhindert of juist helpt om zelfmanagement effectief te ondersteunen.

    Zelfmanagementondersteuning door middel van communicatie is onderzocht voor twee chronische ziekten waarvoor zelfmanagement belangrijk is: HIV en diabetes mellitus type 2. Bij beide ziekten beïnvloedt zelfmanagement de progressie ervan, en bovendien doen patiënten aan zelfmanagement met het oog op hun welzijn, die kan worden aangetast door zowel de fysieke als sociale gevolgen van het hebben van HIV of diabetes type 2. Daarnaast geldt dat communicatie door zorgverleners effecten heeft op uitkomsten voor beide groepen patiënten, maar is er meer inzicht nodig in hoe zorgverleners kunnen communiceren om zelfmanagement effectief te ondersteunen. Het onderzoeken van zelfmanagementondersteuning voor twee verschillende ziekten biedt ook een bredere empirische basis en een beter begrip van de gebruikte concepten.

    Niet alleen wordt zelfmanagementondersteuning voor twee chronische ziekten bekeken, ook worden in de vier empirische studies van dit proefschrift verschillende methodes gebruikt, waaronder een cross-sectioneel surveyonderzoek (Hoofdstuk 2), een thematische analyse van interviews met HIV-patiënten en hun zorgverleners (Hoofdstuk 3), een literatuurstudie naar communicatie in de diabeteszorg (Hoofdstuk 4), en een analyse van opgenomen gesprekken tussen praktijkondersteuners en diabetespatiënten (Hoofdstuk 5). In Hoofdstuk 6 worden de bevindingen van de afzonderlijke hoofdstukken besproken en algemene conclusies gepresenteerd in het licht van de onderzoeksdoelstellingen.

    Hoofdstuk 2 dient als startpunt voor een centraal idee in dit proefschrift, namelijk dat de perceptie van controle een effect heeft op de gezondheid, hetzij direct, hetzij indirect door het effect ervan op gezondheidsgedrag. Zoals betoogd hebben controleconstructen een belangrijke rol in zelfmanagement en kunnen ze theoretisch gezien zowel oorzaak als resultaat daarvan zijn. Percepties van controle kunnen ook een onderdeel zijn van een psychosociale reservecapaciteit die sociaaleconomische gezondheidsverschillen helpt verklaren. Mensen uit de lagere sociaaleconomische strata hebben over het algemeen minder psychosociale hulpbronnen, zoals waargenomen controle over het leven en ervaren sociale steun, terwijl ze tegelijkertijd te maken hebben met meer stressoren die deze hulpbronnen belasten. Met minder hulpbronnen en meer stressoren hebben lagere sociaaleconomische groepen een psychosociale achterstandspositie, die slechtere objectieve en zelf-gerapporteerde gezondheid helpt verklaren, evenals hun suboptimale gezondheidsgedrag. Daarom werd in dit hoofdstuk onderzocht of hulpbronnen en stressoren de relatie tussen opleidingsniveau en gezondheidsgedrag mediëren. Bijkomende doelstellingen waren om te onderzoeken of het ontbreken van hulpbronnen en de aanwezigheid van stressoren kunnen worden weergegeven met een enkele onderliggende factor (d.w.z. de afwezigheid van een hulpbron heeft eenzelfde effect als de aanwezigheid van een stressor), en of een cumulatieve maat van stressoren en hulpbronnen een sterker effect heeft op gedrag dan de afzonderlijke maten.

    Cross-sectionele data werd verzameld onder 3050 inwoners van de stad Utrecht met betrekking tot sociaaldemografische variabelen, psychosociale hulpbronnen, stressoren en gezondheidsgedrag. De resultaten toonden aan dat hogere niveaus van stressoren en lagere niveaus van hulpbronnen inderdaad kunnen worden vertegenwoordigd door een enkele factor. Daarnaast hadden mensen met lagere opleidingsniveaus over het algemeen minder psychosociale hulpbronnen en rapporteren ze hogere stressoren. Stressoren en hulpbronnen medieerden gedeeltelijk de relatie tussen opleidingsniveau en lichaamsbeweging, ontbijtfrequentie, groenteconsumptie en roken. Financiële stress en een slechtere ervaren gezondheid waren sterke mediërende stressoren, terwijl waargenomen controle over het leven en sociale steun sterke mediërende hulpbronnen waren. Echter, de relatie tussen sociaaleconomische positie en gezondheidsgedrag was bescheiden, terwijl de directe associaties tussen stressoren en hulpbronnen met gezondheidsgedrag aanzienlijk waren. Daarom werd geconcludeerd dat de aanwezigheid van stressoren en afwezigheid van hulpbronnen sociaaleconomische verschillen in gezondheidsgedrag helpt verklaren, maar dat het aanpakken van hulpbronnen en stressoren door middel van gezondheidscommunicatie de bevolking als geheel ten goede kan komen. De aanzienlijke impact van slechtere ervaren gezondheidsstatus op gedrag geeft aan dat patiënten inderdaad ondersteuning nodig hebben met het omgaan met een chronische ziekte. Hun gevoel van controle versterken en het bieden van sociale steun zijn mogelijke manieren om dit te doen.

    Hoofdstuk 3 richt zich directer op ondersteuning van zelfmanagement door de communicatievoorkeuren van HIV-patiënten te onderzoeken. In dit hoofdstuk wordt verder gebouwd op studies waaruit blijkt dat de communicatie met zorgverleners belangrijk is voor de ondersteuning van patiënten om zich aan te passen aan hun HIV status en om therapietrouw te zijn, met het oog op het handhaven van hun gezondheid en kwaliteit van leven. Eerdere studies gaven ook aan dat de communicatie optimaal is wanneer die is afgestemd op de voorkeuren van patiënten. Patiënt-zorgverlenercommunicatie dient drie algemene doelstellingen, te weten uitwisseling van informatie, het opbouwen van een relatie tussen zorgverlener en patiënt, en de patiënt betrekken bij behandelingsbesluiten. Het doel van deze studie was om communicatievoorkeuren van HIV-patiënten te verkennen binnen elk van deze drie doelstellingen, en om te onderzoeken hoe patiënten afgestemde - of niet afgestemde - zorgverlenercommunicatie ervaren. Een tweede doel was het verkennen van de overtuigingen van zorgverleners over de voorkeuren van patiënten, alsmede hun perspectief op optimale communicatie. De gegevens werden verzameld door middel van interviews met 28 patiënten en 11 zorgverleners van twee academische ziekenhuizen.

    De resultaten gaven aan dat HIV-patiënten strategisch communiceren met hun zorgverleners om hun gevoel van controle te verhogen. Voorkeuren van patiënten weerspiegelden hun cognitieve, emotionele en praktische behoeften, en patiënten hadden als impliciet doel om hun gevoel van controle over hun HIV status te verhogen door communicatie die deze behoeften dient. Door middel van een vertrouwensvolle relatie met een competente en oprecht betrokken zorgverlener beoogden patiënten hun gevoel van controle te verhogen via ‘volmacht’. De relatie met de zorgverlener verschafte patiënten emotionele steun, maar stelde patiënten ook in staat om hun problemen en zorgen te onthullen, waardoor er verdere mogelijkheden voor het verkrijgen van ondersteuning ontstonden. Deze studie toont dus verder het belang en ook het onderlinge verband tussen controle en sociale steun aan.

    Zorgverleners waren zich terdege bewust van communicatievoorkeuren van patiënten en hun overtuigingen stemden over het algemeen overeen met deze voorkeuren. Echter, zorgverleners leken – tot op zekere hoogte – verantwoordelijkheid te nemen voor de behandeling en patiëntuitkomsten. Dit leek goed te passen bij de voorkeuren van patiënten die graag de verantwoordelijkheid met hun zorgverleners deelden, bijvoorbeeld door niet steeds of volledig betrokken te worden bij de medische besluitvorming. Het kon zorgverleners echter ook aanzetten tot het gebruik van overtuigende communicatie, zoals risicocommunicatie, wanneer patiënten niet therapietrouw waren. Bovendien bleek uit de interviews dat zorgverleners zich niet bewust waren van de controlebehoeften die ten grondslag liggen aan patiëntcommunicatie.

    Hoofdstuk 4 betreft de communicatie tussen type 2 diabetespatiënten en hun belangrijkste zorgverleners die hun zelfmanagement ondersteunen. In Nederland is dat doorgaans de praktijkondersteuner van de huisarts (poh). Eén van de expliciete doelstellingen van de consulten van de poh is het verbeteren van gezondheid van de patiënt door zelfmanagement- ondersteuning. Uit eerder onderzoek blijkt dat patiënten problemen hebben met zelfmanagement, wat resulteert in onvoldoende beheersing van de bloedsuikerspiegel en andere cardiovasculaire risicofactoren. Optimale communicatie kan directe en indirecte gunstige effecten op de gezondheid en het welzijn diabetespatiënten hebben. Echter, uit onderzoek blijkt ook dat poh’s in de praktijk moeite hebben met de communicatie met patiënten. Poh’s worden opgeleid vanuit een voornamelijk biomedisch perspectief en kunnen het daarom moeilijk vinden om de verantwoordelijkheid voor de behandeling en behandelingsresultaten met patiënten te delen. Hierdoor gebruiken poh’s mogelijk communicatiestrategieën die niet daadwerkelijk ondersteunend zijn. Bovendien kan het ondersteunen van zelfmanagement van patiënten problematisch zijn in termen van het veranderen van gezondheidsgedrag zoals voeding en lichamelijke activiteit. Deze gezondheidsgedragingen zijn vaak onderdeel van een jarenlange levensstijl die heeft bijgedragen aan de ontwikkeling van type 2 diabetes. Het doel van dit hoofdstuk is om praktische aanbevelingen te doen om de communicatie tussen poh en patiënt te verbeteren. Dit wordt gedaan door middel van een gestructureerde literatuurstudie gericht op, ten eerste, factoren die effectieve communicatie met diabetespatiënten kunnen belemmeren. Een tweede focus ligt op het bespreken van empirisch bewijs voor methoden die tot doel hebben de communicatie effectiviteit van verpleegkundige communicatie te verhogen.

    Veel voorkomende communicatiebarrières zijn het lichamelijk onderzoek, gebrek aan communicatieve vaardigheden en eigen effectiviteit, en het ervaren van conflicten tussen de rol van medisch expert en de rol van ondersteuner van gedragsverandering. Deze barrières zijn mogelijk gerelateerd aan de context waarin verpleegkundigen werken. Poh’s beginnen namelijk vaak met biomedisch onderzoek en bespreken vervolgens gedragsverandering met patiënten. Echter, gebrek aan vaardigheden en eigen effectiviteit draagt bij aan het gebruik van minder effectieve strategieën zoals alleen advies geven. Effectievere strategieën, zoals het identificeren en aanpakken van belemmeringen om te veranderen, worden minder vaak gebruikt. Poh’s vinden het moeilijk om om te gaan met weerstand van patiënten, en kunnen hun toevlucht nemen tot directieve communicatie, zoals onderbreken van en discussiëren met patiënten.

    Uit de bespreking van effectieve communicatiemethoden blijkt dat het trainen van poh’s in patiëntgerichte counseling niet effectief is in het overwinnen van deze barrières, en mogelijks zelfs nadelige gevolgen heeft voor klinische uitkomsten van patiënten. Daarentegen suggereert beperkt bewijs dat communicatie effectief kan zijn als het is gebaseerd op psychologische principes van zelfregulering, met name het stellen van doelen, het opdelen van doelen in kleine stapjes en actieplanning. De autonomie van patiënten kan worden ondersteund door middel van een relatie met de zorgverlener die is gebaseerd op wederzijds vertrouwen, waarbij poh’s en patiënten samen werken en verantwoordelijkheid delen.

    In Hoofdstuk 5 wordt het 5A’s Model gebruikt om te beoordelen of, en hoe, verpleegkundigen de vijf kernelementen van zelfmanagementondersteuning toepassen. In het vorige hoofdstuk is namelijk besproken dat communicatie effectief kan zijn door de toepassing theorie-gebaseerde counseling voor gedragsverandering. Het 5As Model is gebaseerd op theorie en empirisch bewijs en kan worden gebruikt voor zowel het toepassen als het evalueren van communicatie. De 5As verwijzen naar huidig gedrag beoordelen (‘Assess’), adviseren van gedragsverandering (‘Advise’), afspreken welke duidelijke doelen voor het gedrag (‘Agree’), helpen bij het wegwerken van belemmeringen en het verkrijgen van sociale steun (‘Assist), en vervolgafspraken maken (‘Arrange’). De geïntegreerde en achtereenvolgende toepassing van de 5A’s resulteren in een individueel actieplan, waarin gedragsdoelen en strategieën om deze doelen te bereiken worden beschreven.

    Er is een bestaand instrument gebruikt om opnames van zeven praktijkondersteuners met 66 patiënten te evalueren. Naast de beoordeling óf de 5A’s worden toegepast, worden toegepaste A’s vergeleken met kwaliteitscriteria om te evalueren hoe ze door poh’s worden gebruikt.

    Resultaten lieten zien dat de poh’s gezondheidsgedrag in vrijwel ieder consult met de patiënt beoordeelden. Ook werden individuele vervolgafspraken gemaakt als onderdeel van de standaardzorg. Echter, in minder dan de helft van de consulten adviseerden poh’s gedragsverandering. Het stellen van doelen en het bijstaan van patiënten om belemmeringen voor gedragsverandering te overwinnen werden nog minder gebruikt. De vergelijking met de kwaliteitscriteria liet zien dat verpleegkundigen vrijwel nooit bestaande overtuigingen en emoties met betrekking tot gezondheidsgedrag beoordeelden. Bovendien was de gedragsbeoordeling niet specifiek, waardoor het geven van concrete adviezen en het stellen van doelen werden belemmerd. Als belemmeringen voor gedragsverandering wel werden besproken, dan werden barrières vaak bevestigd maar zonder te brainstormen over strategieën om ze te overwinnen. Alles tezamen werden belangrijke elementen van zelfmanagementondersteuning niet of niet goed toegepast. Daarom wordt aanbevolen dat poh’s worden getraind in het uitvoeren van assessments die de basis vormen voor specifiek advies, doelen stellen en het aanpakken van belemmeringen. Communicatie kan ook verbeteren wanneer poh’s leren hoe de rollen van medisch expert en gedragscounselor te combineren, bijvoorbeeld door beide rollen te verduidelijken aan patiënten.

    Hoofdstuk 6 biedt een samenvatting van de conclusies van de drie empirische hoofdstukken en de literatuurstudie, waardoor de belangrijkste bevindingen aan elkaar gerelateerd kunnen worden en conclusies kunnen worden gepresenteerd die de losse hoofdstukken overstijgen. HIV en type 2 diabetes worden vergeleken, en de belangrijkste bevindingen van het proefschrift worden vergeleken met bestaande literatuur. Hoofdstuk 6 eindigt met mogelijkheden voor toekomstig onderzoek en praktische aanbevelingen voor gezondheidscommunicatie.

    Op basis van de voorgaande hoofdstukken wordt het belang van hulpbronnen zoals gevoel van controle en sociale steun besproken, zowel binnen als buiten de gezondheidszorg. De relaties tussen controlepercepties en sociale steun worden beschreven, en hoe interpersoonlijke gezondheidscommunicatie deze hulpbronnen kan helpen verhogen teneinde zelfmanagement te ondersteunen. De vergelijking van de zorg voor HIV-patiënten en diabetespatiënten wijst op overeenkomsten en verschillen in bestaande communicatie die relevant zijn voor zelfmanagementondersteuning.

    De bevindingen van dit proefschrift worden vergeleken met drie terreinen binnen de wetenschappelijke literatuur die relevant zijn voor zelfmanagementondersteuning: empowerment van patiënten en patiëntgerichte zorg, controle en steun in de psychologie, en implicaties voor zelfmanagementondersteuning. Bijdragen aan de literatuur worden gevolgd door suggesties voor toekomstig onderzoek, gericht op de potentie van controleconstructen om theorieën en studies op het gebied van zelfmanagement te verduidelijken en te verenigen; op het gebied van verantwoordelijkheid nemen en delen in gezondheidscommunicatie; en op het testen van de effectiviteit om zorgverleners te trainen gebaseerd op drie algemene competenties: controlepercepties van patiënten versterken, steunende relaties opbouwen, en theorie-gebaseerde gedragsveranderingstechnieken toepassen. Ten slotte bieden de aanbevelingen voor de praktijk concrete suggesties om communicatie te verbeteren aan zowel individuele zorgverleners als aan de gezondheidszorg als geheel. Zorgverleners kunnen bewust zijn van de onderliggende controlepercepties en -behoeften van patiënten, en proberen deze te identificeren. Dit geldt ook voor de strategieën die patiënten gebruiken om hun gevoel van controle te versterken. Het ondersteunen van zelfmanagement door het ondersteunen van controlepercepties kan worden bereikt door middel van het opbouwen van een steunende relatie en door het bespreken van problemen en zorgen die controlepercepties bedreigen. Tot slot wordt gesteld dat wanneer zorgverleners patiënten willen begeleiden naar gedragsverandering, het systematisch gebruik van theoretisch-gebaseerde communicatiemethoden waarschijnlijk het meest effectief is.

    Home garden: a potential strategy for food and nutrition security in HIV households : a case study in rural Ghana
    Akrofi, S. - \ 2012
    Wageningen University. Promotor(en): Paul Struik, co-promotor(en): Lisa Price. - [S.l. : S.n. - ISBN 9789461732743 - 239
    gezinstuinen - voedselzekerheid - diversiteit - agrobiodiversiteit - hiv-infecties - voedingstoestandbepaling - ghana - home gardens - food security - diversity - agro-biodiversity - hiv infections - nutritional assessment - ghana

    Keywords: Home garden, HIV and AIDS, dietary diversity, plant species diversity, coping strategy index, food security, Ghana.

    The aim of this thesis was to explore how rural households with HIV and AIDS in Ghana are employing home garden management strategies to enhance food and nutrition security and also to examine the seasonal dimension of coping with food insecurity in these rural households through documentation of the frequency and severity of the food–related coping behaviours adopted during periods of peak seasonal food shortages. In Sub-Saharan Africa, home garden cultivation is considered to be a potential strategy for rural households with HIV and AIDS to cope with labour constraints and to improve food and nutrition security. However, existing research that has addressed the relationship between HIV and AIDS, home gardens and food security focused on predictions; there is severe dearth of empirical evidence. Qualitative and quantitative research methodologies were used in this study. Data collection methods included focus group discussions, interviews with key informants, a questionnaire-based survey, in-depth interviews in case studies and participant observations. A 24-hour qualitative dietary recall was used to assess dietary intake of households studied and the Coping Strategy Index was used to assess the severity of household food-related coping behaviours. Data on biophysical aspects of the home gardens was obtained through a home garden survey. The results showed that when labour constraint reduced field cultivation in rural households with HIV and AIDS, labour input in home garden significantly increased; rural households did not cultivate a greater diversity of plant species in home gardens, but rather relatively more food items of the essential food groups were consumed from home gardens. This contributed significantly to dietary diversity. Uncovering the effect of the interaction between household HIV status and gender of the household head on home garden biodiversity indicated that female-headed households with HIV and AIDS depended more on home gardens than their counterparts without HIV and AIDS in producing crops for sustenance and dietary diversity. Exploring the biodiversity in home gardens of rural households with HIV and AIDS when home garden cultivation is also meant to generate cash income revealed that rural households experiencing HIV and AIDS illness in cultivating commerce-oriented home gardens cultivated a dual purpose home garden that provided cash income and also supplied subsistence food. Assessing the frequency and severity of the food-related coping behaviours adopted by farm households with HIV and AIDS during the post-harvest period and in the lean season showed that farm households with HIV and AIDS were more vulnerable to food insecurity in both the post-harvest and lean season; this vulnerability was also reflected in their poverty, family care burdens (larger number of dependents and ill persons), lower education level and meagre income earning opportunity. It is essential that concerted efforts are made to improve the general well-being of farm households with HIV and AIDS by empowering rural households with HIV and AIDS in terms of capacity building, access to livelihood assets and access to finance.


     


     

    Living and care arrangements of non-urban households in KwaZulu-Natal, South Africa, in the context of HIV and AIDS
    Preez, C.J. du - \ 2011
    Wageningen University. Promotor(en): Anke Niehof, co-promotor(en): Gerda Casimir. - S.l. : s.n. - ISBN 9789085859321 - 199
    landbouwhuishoudens - platteland - hiv-infecties - acquired immune deficiency syndrome - ziekte - sociologie - zorg - geslacht (gender) - middelen van bestaan - zuid-afrika - zuidelijk afrika - agricultural households - rural areas - hiv infections - acquired immune deficiency syndrome - illness - sociology - care - gender - livelihoods - south africa - southern africa

    In non-urban KwaZulu-Natal, South Africa, very few households escape the impacts of HIV and AIDS, either the direct impacts as a result of illness and death, or the indirect impacts through providing care and support to family, friends and neighbours. HIV and AIDS becomes part of the context or situation within which households arrange their lives, generate livelihoods and arrange and provide care. The differential impacts of HIV and AIDS on male and female members of different ages within house­holds is poorly documented and understood. How people arrange care, especially for household members who are chronically ill, while generating liveli­hoods at the same time, is even less clear in the context of HIV and AIDS. This research assessed household living and care arrangements and livelihood generation in non-urban Mbonambi in the KwaZulu-Natal province of South Africa, in the context of HIV and AIDS. The study used a combined approach of quantitative and qualitative methodologies. Demographic, socio-economic and health data were collected at the level of the household by means of a survey and results were verified and clarified by means of focus group discussions. For the survey, two research locations were selected, one close to town, with a high population density and fairly good infrastructure and the other further from town and with poorer infrastructure. In the latter location, lack of access to electricity and clean water close to the home adds to the burden of domestic work. In addition, this location also has fewer individuals who are working, with many of those who are working, employed in low paying elementary occupations or working as unskilled labourers. Households at this location also have lower household incomes, are more dependent on state grants and own fewer assets that can be converted to cash if need be.

    Female-headed households proved to be bigger than male-headed ones, having significantly more demographic and effective dependents residing at their home­steads. Female heads are significantly older than their male counterparts, the majority of them widows relying on state old-age pensions as the main source of household income. Female-headed households have significantly lower average incomes and fewer assets than male-headed households. All the households in the survey sample were categorised based on whether and how they were afflicted and/or affected by HIV/AIDS and/or TB, where TB was used as a proxy indicator for HIV infection. Households were allocated to four clusters. Households in Cluster 1 did not experience any impacts attributed to AIDS and included just more that half of al the households. Afflicted households in Cluster 2 had at least one ill member diagnosed with HIV or TB and requiring some care, but did not experience any deaths and were not taking care of orphans. Affected households in Cluster 3 had no ill members, but took care of orphans and/or experienced deaths, while households in Cluster 4 were both afflicted and affected by HIV and AIDS.

    Progression from Cluster 1 to Cluster 4 showed a significant difference in household size, with households in Cluster 4 having on average two more members than households in Cluster 1. Households in Clusters 3 and 4 had significantly more demographic dependents than those in Clusters 1 and 2, while the households hosting orphans in Clusters 2 and 4 had significantly more effective dependents than the households in the other clusters. Although not significant, households in Clusters 2, 3 and 4 had lower household incomes and fewer assets. Of all the households it is clearly visible that households in Cluster 4 that host ill persons and orphans, and experienced deaths, are in all regards worse off than the households in the other clusters, and are extremely vulnerable to livelihood insecurity. Considering that these households have more dependents they will be more severely affected by the lower household income that has to be shared by more persons. Having fewer assets also mean that they do not have anything they can sell when they need money to cover household expenses or to pay for transport or a funeral.

    Case study households were selected from each cluster for further study of their living arrangements and livelihoods. This was done by means of interviews and observations, and each household was visited at least two times over a period of six months. This revealed that the majority of households experienced changes in their living arrangements, regardless of whether and how they were affected by HIV and AIDS. It was especially young people and children who were mobile and individuals were leaving or joining households for a variety of reasons. Young women with or without their children were leaving to look for work, get married or provide care. Mobile children moved between the homesteads of unmarried mothers and biological fathers. The case study households included several households where unmarried mothers were living with their children at the homesteads of their frequently unmarried or widowed mothers.

    Although changes in living arrangements can be caused by many factors other than morbidity and mortality, the majority of cases described experienced changes as a direct result of TB and/or AIDS-related illness and death. The time frame of inter-household movements varies from a few months to several years. The variation in cases presented illustrates that when movements between homesteads take place, the impact of HIV/AIDS-related morbidity and mortality on the livelihood and resources extends beyond the single household.

    It is clearly visible that the majority of households depend on social transfers, either grants from government or private grants, as their only or main source of income, emphasizing the strategic importance of grants in coping with poverty. The financial situation of households may even improve when children receiving grants join a household and are ‘accompanied’ by their grants. But when such children move, the gain of income in one household will translate into a loss for another. Furthermore, some cases show that accessing grants for children is difficult when the status of the child changes and/or the foster parent does not have the required papers. The role of maternal parents or grandparents becomes clear when looking at intra-household cooperation to arrange health care or take care of vulnerable or orphaned children.

    All the households are visited regularly by paid Community Health Workers and/or volunteer Home Based Caregivers, all of them female. These people are well-trained and work closely with the local public health clinic to assist households with care activities, caregivers with emotional support and patients with nutritional advice and traditional treat­ments to maintain health and relief symptoms. This is very important, as none of the HIV-positive persons in this small sample were on antiretroviral (ARV) treatment at the time of the research. Although treatment is free, to access it means regular blood tests and frequent hospital visits, which translates into indirect costs.

    The cases clearly reveal that women are still the main providers of health- and childcare. When the demand on their time to provide care increases, they have less time to devote to income generating and community activities, which means less time to invest in social networks. This will cause already poor households with weak safety nets ‘to fall through’ the vulnerability threshold. All case households reveal the significance of social capital, the net­work of kin in particular, as a source of material and immaterial support. Relatives may take in a child to relieve the household’s burden, may send money, or may provide emotional and practical support. When no relatives are living nearby, the neighbours provide the latter kind of support. At the same time, the cases also show ‘missing’ partners and parents who have opted out and whose where­abouts are sometimes not even known.

    Although the majority of children in the case study households manage to stay in school, they are absent from school more often due to HIV/AIDS-related morbidity and mortality. As a result they fall behind and are at risk of eventually dropping out. Some children choose to stay at the homestead of their late parents, with or without adult supervision rather than moving in with grandparents or other relatives, in an attempt to retain their parents’ homestead and land. This may make children vulnerable to exploitation. Child migration as a strategy to cope with HIV/AIDS-related morbidity was employed by some of the house­holds. Although migration in search of employment has long been common in Southern Africa, migration of ill persons and children seeking care is a much more recent phenomenon.

    Inter-household movements are likely to occur when a household affected by AIDS-related morbidity and mortality does not have the capacity to meet the additional demand for care. Moving of ill persons or vulnerable or orphaned children across house­hold boundaries may make for more efficient use of human, material and financial resources. The cases show a continuous adaptation of living arrangements in response to illness and death. While the homestead and the kinship network still function as important anchors for people’s lives, at the same time HIV and AIDS induce flux and instability, changes dependency relations between homesteads, makes ‘holes’ in safety nets, and undermines relations between partners, in particular those that are not sanctioned by traditional marriage, turning their children into de facto orphans. The homestead also seems to be losing its unified and patriarchal character, though more analysis is needed to prove this, and the supportive role and authority of grandmothers and maternal relatives is increasing. Care is not only morally grounded, it can also add to moral authority.

    The government should look into ways to facilitate better access to ARV treatment, because this would not only improve and prolong the life of people living with HIV, but also contribute to a better quality of life for household members. Streamlining access to foster care grants will prevent households taking care of orphans or orphans living on their own from living in extreme poverty. Increasing the number of well-trained paid community health workers, liaising with formal health care and social workers, will enhance the much need support required by households living with the burden of HIV/AIDS-related morbidity and mortality.

    Although consisting of a very small sample of households studied over a relatively short period of time, this study shows significant HIV/AIDS-induced changes in living arrangements, the variation in the timeframe of these changes, and the impact of these changes on the livelihoods of households and their potential to arrange health- and childcare, thus revealing the mechanisms of micro-level social change induced by the AIDS epidemic. It demonstrates the importance of qualitative research to complement cross-sectional survey research. More qualitative and longitudinal research is needed to know whether in the wake of the epidemic the cultural and social landscape of rural KwaZulu-Natal is fundamentally changing.

    Multi-micronutrient supplementation in HIV-infected South African children : effect on nutritional s tatus, diarrhoea and respiratory infections
    Mda, S. - \ 2011
    Wageningen University. Promotor(en): Frans Kok, co-promotor(en): Joop van Raaij; F.P.R. de Villiers. - [S.l.] : S.n. - ISBN 9789085858577 - 168
    voedselsupplementen - minerale supplementen - vitaminetoevoegingen - humane immunodeficiëntievirussen - hiv-infecties - voedingstoestand - diarree - ademhalingsziekten - kinderen - zuid-afrika - food supplements - mineral supplements - vitamin supplements - human immunodeficiency viruses - hiv infections - nutritional state - diarrhoea - respiratory diseases - children - south africa

    Background: The nutritional status of HIV-infected children is reported to be poor. Diarrhoea and acute respiratory infections tend to be more common and severe in HIV-infected children than in uninfected ones. Deficiencies of micronutrients may result in poor growth and increased risk of diarrhoea and respiratory infections. Micronutrient deficiencies are common in HIV-infected children. The poor growth, diarrhoea and respiratory infections seen in HIV-infected children may be partly due to micronutrient deficiencies. The studies in this thesis had two main objectives: (1) to evaluate the effect of short-term (during hospitalization) and long-term (6 months) multi-micronutrient supplementation on episodes of diarrhoea and respiratory infections in HIV-infected children who are not yet on antiretroviral therapy (ART), and (2) to assess the effects of long-term multi-micronutrient supplementation on appetite and growth performance of HIV-infected who are not on ART.

    Methods and results: Four studies were conducted. Initially a cross-sectional study was performed in which the duration of hospitalization, weight, length, micronutrient status and appetite of HIV-infected children admitted with diarrhoea or pneumonia was compared with the results of HIV-uninfected children. Duration of hospitalization was 2.8 days (52%) longer in HIV-infected children. Appetite as measured by amount of test food eaten (g per kg body weight) was 26% poorer in HIV-infected children. Mean length-for-age Z-scores were lower in HIV-infected children; there was no difference in level of wasting.

    Subsequently multi-micronutrient supplementation studies were performed, one short-term and two long-term studies. The effect of supplementation on the duration of hospitalization in HIV-infected children with diarrhoea or pneumonia was assessed in the short-term study. One long-term study assessed the supplement’s impact on growth and frequency of episodes of diarrhoea and of pneumonia in HIV-infected children. The other evaluated the effect of the supplement on the appetite of these children. The supplement contained vitamins A, B complex, C, D, E and folic acid, and the minerals copper, iron, selenium and zinc at levels based on recommended dietary allowances.

    In the short-term supplementation study HIV-infected children aged 4-24 months who were hospitalized with pneumonia or diarrhoea received the supplement or a placebo until discharge from hospital. The duration of hospitalization was 1.7 days (19%) shorter in the supplement group.

    Long-term multi-micronutrient supplementation improved the weight-for-age and weight-for-height Z-scores of HIV-infected children aged 4-24 months by 0.4 over the 6-month period. There was no improvement in stunting. Children in the supplement group had substantially fewer episodes of respiratory symptoms per month than the placebo group (0.66 ± 0.51) per month vs (1.01 ± 0.67) (P < 0.05) and marginally fewer episodes of diarrhoea per month (0.25 ± 0.31) vs (0.36 ± 0.36) (P = 0.09). There was no effect on CD4 lymphocytes. Long-term supplementation with micronutrients had benefits on the appetite of HIV-infected children aged 6-24 months as well. Improvements in amount of test food eaten over the 6-month period were much higher among children who received the supplement (4.7 ± 14.7 g/kg body weight) than the changes in those who received the placebo (-1.4 ± 11.6 g/kg body weight).

    Conclusion: Multi-micronutrient supplementation reduces the duration of diarrhoea and of pneumonia and incidence of diarrhoea and of respiratory symptoms in HIV-infected children who are not yet on ART. Multi-micronutrient supplementation also improves appetite and weight in these children but not height. The results of these studies indicate that multi-micronutrient supplementation should be considered in HIV-infected infant and young children who have not commenced ART.

    The quest for sustainable livelihoods : women fish traders in Ibaka, Niger Delta, Nigeria
    Udong, E.E. - \ 2011
    Wageningen University. Promotor(en): Anke Niehof, co-promotor(en): Aad van Tilburg. - [S.l.] : S.n. - ISBN 9789085859345 - 317
    vrouwen - geslacht (gender) - vis - markthandelaars - handel - strategieën voor levensonderhoud - duurzaamheid (sustainability) - duurzame ontwikkeling - visverwerking - marketing - sociologie - hiv-infecties - acquired immune deficiency syndrome - nigeria - afrika - women - gender - fish - market traders - trade - livelihood strategies - sustainability - sustainable development - fish processing - marketing - sociology - hiv infections - acquired immune deficiency syndrome - nigeria - africa

    The contribution of fisheries to food security in Africa cannot be underestimated. It provides

    over 30 percent of the protein consumed by the Nigerian population. However, Nigeria

    produces only about 45 percent of the fish requirement locally while the shortfall of about 55

    percent is imported. Over 80 percent of the local production is from the artisanal, small scale

    sector. While several studies have been conducted on the productivity of many water bodies,

    endemic fish species, different fisheries, boats mechanization and the role of the fishermen,

    socio-economic and gender issues in fisheries have received scant attention. Such research has

    therefore become necessary for the development of relevant policies and intervention

    programmes. The sustainable livelihood approach was used in facilitating the understanding of

    how the women fish traders’ livelihoods are created, sustained and constrained by a set of

    complex factors and processes including institutions and culture. The main objectives of this

    study were to:

    1. Contribute towards the livelihood and gender theory by focusing on the performance of

    women fish traders in the economic and domestic domains in a coastal fishing

    community, given the institutional and cultural constraints, their vulnerability and

    susceptibility to HIV and AIDS;

    2. Identify the implications for household food and livelihood security and the critical

    factors needed to be considered in the development of relevant policies that would

    ensure sustainable livelihoods and lower vulnerability levels for the women fish traders

    and their households.

    Specifically, the study aimed at highlighting the complexity of sustaining rural

    livelihoods by women fish traders in a coastal fishing community in Nigeria and the flexibility

    and variation, which give the fish trading system its continuing ability to link other commercial

    and non-commercial sectors, characterised by constantly shifting relationships. A gender

    perspective was applied throughout the study. The study was carried out in Ibaka, a dynamic

    commercial centre and the largest coastal fishing community in Akwa Ibom State in the Niger

    Delta of Nigeria, which is largely undeveloped but has over 70 percent of the population

    depending on the fisheries for their livelihood. A cross-sectional study design was used, in

    combination with qualitative and quantitative research methods. Apart from being descriptive

    in nature, an analytical approach was also used by arranging and processing the collected data

    in different ways and through testing different hypotheses.

    Due to the large variation in the range and scale of enterprises obtained, the fish traders

    comprise some of the largest wholesalers on the Nigerian coastline and some of the poorest

    strolling hawkers, living from hand-to-mouth. This is a characteristic feature of a major

    market, and the study seeks to identify the key social, economic and institutional forces, which

    generate, maintain and continue to reshape this diversity. The forces originate from the market,

    its links with the household, community, and national level processes, which create conflicting

    interests and pressures on the individual fish traders as they struggle for survival and the

    accumulation of wealth. These contradictions renew and transform the trading relations,

    including their constraints.

    The main household resources available and accessible were the labour of the women

    fish traders themselves and the female members of their families. Through family ties,

    churches, professional associations, social clubs and osusu groups trade networks and social

    churches, professional associations, social clubs and osusu groups trade networks and social

    capital, on which depended success in the fish trade were developed. The economic resource

    was the different species of fish provided by the sea. The physical resources included equipments such as boats, nets, outboard engines, landed properties, houses, and mobile

    phones. The women also used their own trading and language skills, and years of experience in

    the trade to their advantage. Those with sufficient years of education also deployed their

    educational skills to their advantage. The gendered nature of the fish trade and the fact that it

    requires professional skills ensures that labour is expensive to hire. Only very few women fish

    traders, operating on a large scale and earning higher incomes possessed tangible assets, and

    were able to acquire equipments such as outboard engines, fishing and transport boats, and

    other assets such as land, houses, generators, deep freezers, market stalls as well as fish trade

    titles

    Processing and trading in either bonga, big fish or crayfish, and providing labour for

    fish processing remain the main livelihood strategies and the main source of livelihood for

    most women fish traders in Ibaka. Most of the incomes used for the maintenance of their

    children and households are derived from these. Diversification into other economic activities

    including fashion designing, subsistence farming, food processing, money lending, food

    vending and petty trading is also adopted by most women, while the better-off are involved in

    water transportation, equipment leasing, money lending, bukka business. The strategies

    adopted are affected by factors such as age, skills acquired, years of experience, working

    capital available for the trade, educational status, and number and ages of children. Younger

    traders try to acquire other skills and formal education to enable them diversify while the older

    women concentrate on earning higher incomes through developing their social capital,

    expanding their networks, and making better business connections, to enable them diversify,

    educate their children and secure their livelihoods

    The study identifies three groups of women fish traders in Ibaka: the bonga, big fish

    and crayfish traders, who all operate as small, medium and large scale traders, depending on

    the amount of working capital used. Many similarities were observed in the lack of access to

    resources, lack of infrastructural facilities, the mode of recruitment into the trade, the

    involvement of family members, the use of social capital, and the use of incomes for the

    livelihood sustenance of their households. However, significant differences by age, educational

    status, years of experience, working capital and wealth status were observed between the three

    fish trade groups. Big fish traders with older members had more experience, higher working

    capital and incomes, and consequently more assets than bonga and crayfish traders. In

    addition, limited access to resources for most of the poor fish traders, especially from the

    bonga group, forced them into activities that yielded low returns, such as casual labour and

    subsistence farming, re-enforcing their poor performance in the economic and domestic

    domains.

    The study shows that the fish trade is a gendered activity, and the most profitable

    livelihood strategy undertaken for the sustenance of households in Ibaka, providing the women

    with incomes used for the maintenance and upkeep of their households, and the payment of

    their children’s school fees, healthcare bills and other needs.

    However, in spite of their different circumstances, interests and opportunities, the

    women fish traders all face similar risks, shocks and stress, associated with their location and

    environment. These include seasonality, conflicts, and HIV and AIDS, as well as institutional

    and cultural constraints, which make them vulnerable. The institutional constraints identified

    include lack of physical and marketing infrastructure, financial services, and access to

    resources, information asymmetries, high transaction and labour costs, while the cultural

    constraints include the beliefs, taboos, ethnicity, norms, values and family life. The adaptation

    strategies used for the institutional constraints included buying and selling on credit, use of

    social capital and networking, membership of osusu groups, patronising local money-lenders,

    use of family labour, including under-aged children, sourcing for water from shallow wells and

    commercial boreholes for washing and drinking respectively, patronising traditional health

    practitioners and patent medicine stores, and the churches over their health problems. On the

    other hand, the adaptation strategies for the cultural constraints included intermarriage with the

    indigenes, joining associations and clubs, working from home on days of cultural festivals,

    non-pooling of incomes and striving for independence and autonomy.

    Apart from the cultural and institutional constraints the study shows that the fish trade

    is affected by seasonality which is a major cause of vulnerability. During the lean season which

    covers about six months of the year, fishing activities and incomes are reduced to a minimum

    for all the fish species due to high fish prices at the beach and insufficient working capital. The

    traders then experience periods of food shortage and hunger in the household, making them

    highly vulnerable and susceptible to poverty and HIV and AIDS. Fire incidents and conflicts

    also contribute to their vulnerability.

    The study shows that participation in the fish trade is through kinship and marriage, and

    only women who possess specific skills, working capital, available networks and social capital,

    and belong in a certain culture, location and ethnicity can participate. It is also determined by

    household structures, gender division of labour, marriage, residence and inheritance patterns.

    However, in the absence of functional institutions, and with several cultural barriers to contend

    with, the fish trade, which is often regarded as an extension of household tasks embarked upon

    to ensure the livelihood sustenance of the household, is carried out by the women fish traders

    using social networking and social capital, to facilitate their trading profession. Sources of

    social capital include kin, neighbours, friends, matron-client relationships, mutual trust, osusu

    groups, social clubs and associations, norms and values, and churches.

    The study shows that the Ibaka fish market, like most rural food markets in West

    Africa, operates without any supporting structures. It lacks infrastructural facilities and access

    to information, with a non-existent line of communication between the women fish traders and

    the consumers. The provision of an improved communication system, infrastructural facilities,

    credit systems and adequate information would therefore reduce the transaction costs and make

    for a better coordination mechanism in the market. The study also shows that the fish market in

    Ibaka operates through incomplete contract transactions, where it is impossible to reach an

    agreement in advance about all possible events that could affect the exchange. Even though it

    is a rural market dealing with a single commodity, and does not quite fit into the modern urban

    market category, it possesses many attributes of an imperfect market. These include nonhomogenous

    products, fewer buyers and sellers, no market transparency and barriers to entry

    and exit. The various types and degrees of market imperfection characterise Ibaka market as a

    missing market and a thin, incomplete and interlocked market.

    The study shows that performance in the economic domain is mainly determined by the

    women fish traders’ ability to mobilize sufficient working capital from different sources and

    arrange for regular supply of fish, social capital and networking ability, the years of

    experience, skills acquired, the ability to pay for labour, the profitability of the enterprise, level

    of income, the ability to save, their assets base and wealth status, among others. Performance in

    the domestic domain is determined by the ability to educate children, the type of housing, the

    energy type used for lighting and cooking, the health status of the household, and the number

    of hours spent in the household.

    The study shows that performance in both domains is influenced by age, years of

    experience, skills acquired, amount of working capital used, educational status, status of

    mother in the trade, social capital and the number of children. The women fish traders also

    derive potential benefits associated with their location if they successfully adapt to the

    conditions and adopt sustainable livelihood strategies. All these together, affect their

    performance in the economic and domestic domains, and their success at maintaining the

    livelihoods of their households. The big fish and crayfish traders seemed to perform better than

    the bonga traders generally, both in the economic and domestic domains.

    The study also shows that good performance in the economic domain engenders good

    performance in the domestic domain because the possession of sufficient incomes enables the

    women to feed and educate their children, maintain a healthy household and take care of

    themselves. Sufficient incomes also engender the ability to own or live in permanent structures

    in the community and the use of generating sets for lighting and kerosene stoves for cooking in

    the households. However, the lack of basic information and documentation on HIV and AIDS

    in Ibaka has made it impossible to determine how susceptible and vulnerable the women fish

    traders and their families are to the disease even though evidence from fishing communities in

    other countries has shown fisherfolk to be more vulnerable than rural upland populations.

    In conclusion, the resilience of the women fish traders and their survival in the fisheries

    sector can be explained through the rigid and gendered division of labour. This is backed by

    the determination of the women to become independent economically and overcome the

    cultural biases imposed through patriarchy, polygamy and discriminatory inheritance laws.

    Also, there is the incentive of being able to take care of themselves and their children, gain

    some power, agency and autonomy. The realization that men depend on the women to dispose

    of their fish catches, giving the fish economic value, further strengthens the position of the fish

    traders in the fishery economy of Ibaka. The women fish traders’ conversion of profits made

    from the fish trade into ownership of fishing and transportation boats is true entrepreneurship.

    Using new and innovative ways of finding new or acquiring more customers and accumulating

    capital is also entrepreneurial. However, there is far less risk, both socially and economically,

    in expanding the scope in the trade and climbing in the female market hierarchy than in

    investing in a male domain.

    The fact that the women fish traders live in the same community and locality, and are

    exposed to similar institutional and cultural constraints does not mean that there are no

    differences between the three fish trade groups. The constraints impact differentially both

    within and between the groups and the strategic responses depend on the category the fish

    trader belongs to within the group and her wealth status in the trade and the community.

    Environmental factors and processes such as climate change and oil pollution, and the general

    economic crisis, also make fisherfolk vulnerable and susceptible to HIV and AIDS. While the

    government is trying to extend development to the rural areas, it is pertinent that remote

    communities like Ibaka should be specially targeted. Gender mainstreaming should also be

    incorporated in the development process in order to reduce glaring inequalities, with certain

    social groups being marginalized while others are privileged. This will reduce the women

    traders’ level of vulnerability to constraints, stresses, risks, and shocks in our rural

    communities.

    AIDS and Rural Livelihoods. Dynamics and Diversity in Sub-Saharan Africa
    Niehof, Anke ; Rugalema, G. ; Gillespie, S. - \ 2010
    London : Earthscan - ISBN 9781849711265 - 234
    ontwikkelingsstudies - acquired immune deficiency syndrome - humane ziekten - hiv-infecties - volksgezondheid - platteland - plattelandsbevolking - sociale economie - rurale sociologie - economische aspecten - afrika ten zuiden van de sahara - landbouwhuishoudens - development studies - acquired immune deficiency syndrome - human diseases - hiv infections - public health - rural areas - rural population - socioeconomics - rural sociology - economic aspects - africa south of sahara - agricultural households
    HIV and AIDS continue to devastate the livelihoods of millions of Africans and represent the major public health challenge in many countries. More people die of AIDS each day than from wars, famine and floods combined, while an orphaned generation of children must be provided for. Yet despite millions of dollars of aid and research, there has previously been little detailed on-the-ground analysis of the long-term impact on rural people. This book brings together recent evidence on HIV/AIDS impacts on rural households, livelihoods, and agricultural practice in sub-Saharan Africa. There is particular emphasis on the role of women in affected households. The book presents micro-level information collected by original empirical research in a range of African countries, and shows how well-grounded conclusions on trends and major problems can then be addressed by policies. It is shown that HIV/AIDS impacts are more diverse than we know (and not always negative) on the basis of cumulative evidence so far.
    Efficacy of micro-financing women's activities in Côte d'Ivoire : evidence from rural areas and HIV/AIDS-affected women
    Binaté Fofana, N. - \ 2010
    Wageningen University. Promotor(en): Gerrit Antonides; Anke Niehof, co-promotor(en): Johan van Ophem. - [S.l.] : S.n. - ISBN 9789085854289 - 209
    development studies - women - rural women - hiv infections - human immunodeficiency viruses - acquired immune deficiency syndrome - public health - socioeconomics - rural areas - empowerment - finance - credit - cooperative credit - cote d'ivoire - west africa - developing countries - microfinance - ontwikkelingsstudies - vrouwen - plattelandsvrouwen - hiv-infecties - humaan immunodeficiëntievirussen - acquired immune deficiency syndrome - volksgezondheid - sociale economie - platteland - empowerment - financiën - krediet - coöperatief krediet - ivoorkust - west-afrika - ontwikkelingslanden - microfinanciering
    This thesis deals with the effectiveness and the capability of microfinance institutions in enhancing women’s livelihood and empowerment, and mitigating the effects of HIV and AIDS on affected women and their households in Côte d’Ivoire. This study was carried out within the framework of the AWLAE (African Women Leaders in Agriculture and Environment) Project. The AWLAE project addresses the theme of the role of women in food systems and effects of HIV and AIDS on rural livelihoods.

    Microfinance has been recognized as a significant means of economic development in developing countries, especially in Africa where most of the economies are based on agriculture. Microfinance as a credit institution is seen as one of the relevant tools that can provide small loans for poor people especially women who have no access to formal banks. Therefore MFIs have attracted more attention from governments, NGOs, researchers and civil servants since the microcredit summit in 1997 and the nomination of the year 2005 as the International Year of Microcredit by the United Nations General Assembly.

    Studies have shown that the effects of MFIs on women’s activities differ between countries and between regions within countries according to factors including the environment, and the socio-demographic characteristics of the beneficiaries. This heterogeneity renders the effects of MFIs inconclusive and explains the necessity and the relevance to conduct this empirical study in Côte d’Ivoire.

    The objective of this study is to gain insight into women’s needs in terms of support for economic activities and empowerment in rural areas and the way in which MFIs address these needs. Specifically, the study aims at assessing whether microfinance services provided for women in Côte d’Ivoire fit their needs in terms of improving their incomes, productivity, decision-making power, human and social capital. Special attention is paid to HIV-affected women. To achieve these objectives, the study tends to respond to four main research questions: 1) What are women’s needs for credit in rural areas? 2) How do women have access to MFI credit in rural areas? 3) What are the effects of participation in microfinance programs on women’s practical and strategic gender needs? 4) What is the relationship between microfinance programs and women coping with HIV/AIDS? These research questions lead to the formulation of hypotheses that are confirmed or rejected.

    This study uses both a theoretical and empirical approach that represents the interaction of women’s livelihood, microfinance and HIV and AIDS. The empirical analysis consists of an in-depth analysis of microfinance institutions and a survey analysis applied to cross-sectional data collected from 440 women in the Abengourou region located in the Central Eastern part of Côte d’Ivoire. The sample was divided into four categories of women as follows: Non-HIV affected women with and without MFI credit; HIV-affected women with and without credit.

    This study gives a descriptive analysis of the study country, and the response of the state to promote the microfinance sector and to mitigate the effects of HIV and AIDS on the individual, household and communities in Côte d’Ivoire. Women in the Abengourou region are basically involved in agriculture from which they earn their livelihood and the opportunity to produce food for household consumption. The type of activities carried by women depends on their access to credit. Those who have no access to MFI loans were mainly engaged in farm activities while women with access to credit were mainly traders. They were also able to undertake both agricultural and trade activities. From these results, it appears that women in rural areas need MFI credit for trade purposes and to a lesser extent for agricultural activities.

    This study found a significant relation between savings and credit, meaning that access to MFI credit was fundamentally conditioned on the provision of savings from the borrowers that most of the rural population did not have. MFIs use savings as collateral to prevent defaults. In addition, MFI membership and the type of activity are also important to obtain MFI credit. Furthermore, access to MFI credit depends on factors linked to the characteristics of female borrowers including, marital status, wealth status of the household, ethnicity and the empowerment of women, and trade activity. These determinants positively affect the probability of obtaining MFI credit in rural areas. The study reveals that MFIs prefer to finance trade activity rather than agricultural activity as the latter is seen as risky and associated with unpredictable income.

    The use of the propensity score matching method led to the following results. MFIs are found to be effective in enhancing a set of variables including income, the level of farm production, human and social capital. MFI credit has enhanced women’s decision-making power within the households too. However, women’s access and use of MFI credit in rural areas did not significantly increase the value of women’s assets but it did significantly enhance the value of household assets. This result on the value of women’s assets did not confirm the findings of several studies which indicated that the provision of credit enables women to build up and improve the value of their assets (Rahman, 2004; Mayoux, 1999, Van Maanen, 2004). The result also suggested that female borrowers were more likely to use their income earned not to build their own assets, but to contribute to the improvement of the household standard of living. Doing so enables these women to achieve more power in fulfilling their practical and strategic gender needs within the household as indicated by the findings of this study.

    The effectiveness of MFIs in providing loans for women in rural areas is measured by the loan repayment which is an important indicator for MFI practitioners. It gives insight into the capability of the credit institution to insure its sustainability and to increase its outreach. From our analysis, loan repayment among female borrowers generally was not successful as some borrowers had difficulties to pay back their MFI loan. The non-repayment is mainly explained by the diversion of loans from investment purposes, which has to do with the lack of women’s control over loans. For MFIs, the diversion of loans can endanger their functioning and sustainability and therefore their effectiveness in rural areas. However, this study found the low repayment performance of female borrowers to be contradictory to the positive effect of MFI credit on women’s income and the positive return on investment they achieved. Hence, this study suggests that in addition to the diversion of loans, non-repayment might be linked to other factors especially the unwillingness of the borrowers to repay their loan.

    The analysis of the interaction between HIV/AIDS, women’s livelihood and MFIs reveals on the one hand that HIV and AIDS negatively affects both human and physical capital of households through morbidity and mortality. The morbidity of affected women results in a direct negative impact on their livelihood activities and an indirect effect on their income and loan repayment. HIV/AIDS has an impact on the morbidity of household members that leads to the loss of family labour, which is difficult to replace due to lack of resources. In addition, the morbidity results in a drop in the level of education as children are forced to stay at home due to illness. On the other hand, the negative effects of HIV and AIDS on female borrowers entail an indirect effect on MFIs through the incapability of affected borrowers to generate more money and inability to payback their loans. This result essentially has to do with the diversion of loans to meet medical expenditures and the process of the provision of loans that appears to be flawed. In line with this deficiency, the functioning and the effectiveness of MFIs to support and extend their outreach among HIV-affected individuals or households are threatened.

    This study contributes to the existing findings about the socio-economic role of MFIs to support women generating their livelihood. It gives empirical findings in the case of rural areas in Côte d’Ivoire. Such study was not done since the implementation of microfinance institutions in the Abengourou region. The study reveals that the activities carried by women can be influenced by their need to have access to MFIs. This means that women will choose to undertake a particular activity to fit the preferences of microfinance institutions. Another important contribution of this study is to empirically link women’s empowerment to their access to MFI credit. The study reveals that women’s empowerment regarding the demand for and the use of credit make them more reliable and give them more opportunity to obtain MFI credit. With regard to HIV, this study highlights the diversity and the specificity of the way HIV-affected individuals are financially supported by credit institutions.

    To conclude, the study provides some policy recommendations and interventions in order to make MFIs more effective in offering financial services to individuals and households in general and women in particular in rural areas. Specifically we recommend the provision of loans taking into account the needs of borrowers with respect to the special nature of their activities to be financed. MFIs need subsidies from the state or other potential donors to reinforce the capacity building of MFI credit officers through training and to support the transaction costs linked to the provision of small loans. Doing so will help them to better understand and serve the rural population living in an environment which seems to be complex. The study also recommends further study to be conducted in order to explore the long-run effects of MFI credit in rural Côte d’Ivoire.

    The combat for gender equality in education : rural livelihood pathways in the context of HIV/AIDS
    Kakuru, D. - \ 2006
    Wageningen University. Promotor(en): Martin Mulder, co-promotor(en): Margreet van der Burg; Arjen Wals. - [S.l.] : S.n. - ISBN 9789085045090 - 235
    primair onderwijs - gezondheidseducatie - man-vrouwrelaties - platteland - afrika - acquired immune deficiency syndrome - hiv-infecties - plattelandsgemeenschappen - uganda - geslacht (gender) - gelijke behandeling van de vrouw - primary education - health education - hiv infections - acquired immune deficiency syndrome - gender relations - rural communities - rural areas - africa - uganda - gender - female equality
    The research sought to understand the reasons for the persistence of gender inequalities in Universal Primary Education (UPE) even after deliberate measures had been put in place to address them. This research was designed to take a balanced perspective of how inequalities result from the complex interaction between school and structural processes. I specifically focused on how educational gender inequalities result from individuals' pathways in response to the socio-economic impact of HIV/AIDS on their livelihoods. The research objectives revolved around issues relating to the impact of HIV/AIDS on household investment in education and teacher competence to promote gender equality. The impact of HIV/AIDS was also analysed in relation to other school specific factors such as classroom interaction and children's educational rights. Lastly, I underline the framework proposed for better understanding of gender equality in UPE.

    The first objective of the study was to establish how the effect of HIV/AIDS on the livelihoods of rural households conflicts with investment in girls' education. The findings reported in chapter 2 revealed that HIV/AIDS had depleted household members' access to livelihood assets particularly financial capital and human capital. This is due to the entrenchment of AIDS-induced poverty and AIDS orphanhood. It is well acknowledged that people in the study villages were already poor even before the onset of HIV/AIDS. However, judging from the life stories and other data collected, I noticed that HIV/AIDS has indeed added fuel to the fire. This fire does not stop burning at the household level but its impact is felt in all aspects of the society. The situation is not helped by the endurance of unequal power relations. The societal norms, values, beliefs, practices and patterns maintain a gendered household division of labour, decision-making and resource allocation. This gendered nature of social life silently influences individuals' pathways in response to HIV/AIDS impact. Synthesis of the data shows that people's pathways are not compatible with equality in general and girls' schooling in particular. For example, because households have lost productive labour due to illness and death, they are stressed with poor agricultural production and the associated food and income insecurity. The issue of how household responses or individual pathways to AIDS-related livelihood stress counteract the struggle for gender equality is the contribution of chapter 2 of this thesis to existing knowledge.

    The second objective was to find out the effect of household responses to the impact of HIV/AIDS on teacher competence to promote gender equality. I wanted to know how HIV/AIDS impact on rural household livelihoods had undermined teacher competence to promote gender equality. The findings reported in chapter 3 show that AIDS-related livelihood stress intervenes with teacher competence. Pupils in the context of HIV/AIDS face many livelihood problems including lack of learning materials, lunch, clothes, parents, and a favourable school environment. Some children affected and made vulnerable by HIV/AIDS are required to miss school often, or arrive later at school. Others are compelled to go without learning materials. Some children have only the evening meal at home because breakfast is not a norm in their households and there is no lunch at school. However, teachers are not aware of pupils' home situations. They expect children to be at the right place at the right time doing the right thing. Pupils in UPE schools complained about corporal punishment by teachers due to lack of materials or poor performance in classroom exercises. The question is whether teachers have the necessary competencies to promote gender equality in the context of HIV/AIDS. Synthesis of field data revealed a need to develop certain core competences for primary school teachers in light of the HIV/AIDS impact and this forms the major contribution of chapter 3 to the existing body of knowledge. Five competencies specifically identified in this research are Interpersonal competence, Pedagogical competence, Subject matter knowledge and methodological competence, AIDS competence, and Gender competence. Development of the identified competencies could possible through putting in place job profiles for teachers to align teacher development, and performance standards with school and contextual needs. Reforming teacher education and improving the working conditions for primary teachers could also enhance the development of desired competencies.

    The third objective was to identify other school related factors that hinder gender equality in the context of HIV/AIDS. These were identified as classroom interaction children's educational rights. The significance of HIV/AIDS to classroom interaction and gender inequalities in pupils' academic competencies is addressed in chapter 4 . The thesis explains how the gendered nature of classroom interaction and pupils' academic competencies follow from the impact of HIV/AIDS on rural livelihoods. The major contribution was on explaining the extent to which gender differences in pupils' academic competence were due to HIV/AIDS. This thesis addresses the issue of children's educational rights in chapter 5 . In this chapter, gender equality is perceived as equality of capabilities to enjoy rights entitlements in education drawing on the capabilities approach (Sen, 1980; 1992; 1999, Nussbaum, 2000). The chapter discusses how gender inequality in pupils' capabilities to enjoy educational rights accrues from the impact of HIV/AIDS on their livelihoods.

    The fourth objective of this research was to propose a framework for understanding the persistence of gender inequalities in UPE and the results are reported in chapter 6. This chapter is a synthesis of the findings of the previous chapters (2, 3, 4 and 5) in an attempt to propose a framework for better understanding of the persistence of inequalities. I emphasise the need to refocus our perceptions in the bid to strengthen the combat for gender equality. Rather than look at gender equality in terms of numbers (or how many children of each sex are enrolled or attend school regularly), it is important to look at it as a human rights issue as I elaborated in chapter 4.

    In conclusion, HIV/AIDS contributes to inequalities through reinforcing the existing structural hindrances. In other words, even if there were to be no HIV/AIDS, inequalities would probably persist but of course, the magnitude would differ. Nevertheless, the contribution of HIV/AIDS is considerable enough to warrant urgent action. There is therefore need for stronger mechanisms to mitigate the impact of HIV/AIDS on rural livelihoods. In addition, educational reforms and a general social transformation would strengthen the combat for gender equality in the context of HIV/AIDS.
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