Publication

Community Engagement for Stakeholder and Community Trust in Healthcare: Short-term Evaluation Findings from a Nationwide Initiative in Lao PDR

Abstract

Background

Trust remains a critical concept in healthcare provision, but little is known about the ability of health policy and interventions to stimulate more trusting relationships between communities and the health system. The CONNECT (Community Network Engagement for Essential Healthcare and COVID-19 Responses Through Trust) Initiative in Lao PDR provided an opportunity to assess the community-level impact of a trust-building community engagement approach.

Methods

A mixed-method process evaluation was implemented from 10/2022–12/2023 among 14 diverse case study communities in four provinces across Lao PDR. Data collection involved two rounds of census surveys (3161 observations incl. panel data from 618 individuals) including an 8-item trust scale, 50 semi-structured interviews with villagers, and 50 contextualizing key informant interviews. The two data collection rounds were implemented before and three months after village-based CONNECT activities and helped discern impacts among activity participants, indirectly exposed villagers, and unexposed villagers in a difference-in-difference analysis.

Results

Stakeholders attested strong support for the CONNECT Initiative although community-level retention of trust-related themes from the activities was limited. Quantitative data nevertheless showed that, at endline, the 8-item trust index (from [–8 to +8]) increased by 0.95 points from 4.44 to 5.39 and all trust indicators were universally higher. Difference-in-difference analysis showed that villagers exposed to the CONNECT activities had a 1.02-index-point higher trust index compared to unexposed villagers. Trust impacts improved gradually over time and were relatively more pronounced among men and ethnic minority groups.

Conclusions

The CONNECT Initiative had considerable direct and systemic effects on community members’ trust in their local health centers in the short term, which arose from strong stakeholder mobilization and gradual institutional learning. Relational community engagement approaches have the potential to create important synergies in health policy and broader cross-sectorial strategies, but also require contextual grounding to identify locally relevant dimensions of trust.

การสร้างความทรงจำผ่านอาหาร: การศึกษาความทรงจำ, พื้นที่และผัสสะ

บทคัดย่่อ

บทความนี้้นำเสนอแนวทางการศึกษาที่่ใช้อาหารเป็นวัตถุุทางวัฒนธรรมในการสร้้างความทรงจำทั้้งปัจเจกบุุคคลและความทรงจำร่วมในสังคม จุุดประสงค์หลักคือ การทบทวนแนวคิด ทฤษฎี และกรณีศึกษาเพื่่อนำไปใช้ทำความเข้้าใจกระบวนการสร้้างความทรงจำที่่สามารถปรับเปลี่่ยนหรืือถููกกระตุ้นด้วยอาหาร บทความนี้้นำความทรงจำมาเป็นจุุดเริ่มต้นของการประกอบสร้างความหมายของอาหารโดยเฉพาะมุมมองที่่นำอาหารมาเป็นศููนย์กลางในการศึกษาเพื่่ออธิบายโครงสร้างทางสังคมและวัฒนธรรม ซึ่่งเป็นการอธิบายความสัมพันธ์ระหว่างอาหาร และความทรงจำที่่

สัมพันธ์์กับแนวคิดมานุุษยวิทยาอาหารซึ่่งนำเสนอพัฒนาการการศึกษาอาหารจากช่วงเวลาต่าง ๆ จากนั้นทบทวนกระบวนการสร้างความทรงจำผ่านการรับรู้อาหารผ่านผัสสะ ได้แก่ รสชาติและกลิ่นซึ่งเป็นแง่มุมสำคัญในการศึกษาอาหาร หัวข้อสุุดท้ายพยายามเชื่อมโยงกับความสำคัญของ

พื้้นที่่ที่่ก่อให้เกิดความทรงจำที่่เชื่่อมกับอาหาร ความทรงจำและพื้นที่่เฉพาะ ดัังนั้้นบทความนี้้นำเสนอที่่มาที่่ไปของการสร้างความทรงจำผ่านอาหารและนำเสนอวิธีการศึกษาอีกวิธีหนึ่งในการทำความเข้าใจและสำรวจพื้นที่่การศึกษาอาหารใหม่ๆ ที่่ยังไม่ได้รับความสนใจเท่่าที่่ควร

Trust in healthcare: methodological and conceptual insights from mixed-method research in Lao People’s Democratic Republic

Background

Global health foregrounds trust as a key requirement for the achievement of international health initiatives, but it remains an elusive concept that is often mobilised without consideration of its dimensions, drivers and downstream behavioural consequences. This paper aims to contribute to the conceptual development and measurement of ‘patient trust in primary healthcare’ from the lower middle-income country perspective of rural Lao PDR.

Methods

A two-phase mixed-method research design was implemented between January 2021 and April 2023. Phase 1 involved exploratory qualitative research to understand the local expressions and dimensions of patient trust in primary healthcare, with 25 semistructured interviews and 17 focus group discussions (120 participants) in eight villages in Bokeo Province. Phase 2 involved explanatory research to assess patterns of trust systematically at scale in 14 villages across four provinces, wherein 26 cognitive interviews, 17 expert interviews and non-participant community observations informed a community census survey with 1838 participants. We analysed qualitative data through content-oriented thematic analysis and developed an 8-item trust scale on that basis. Quantitative data analysis used descriptive statistical and regression analysis.

Results

We found that trust in primary healthcare is readily understood and intrinsically valuable in rural Lao PDR. Key dimensions included communication, respectful care, relationship, fairness, integrity, reputation, assurance of treatment and competence. The survey highlighted that reputation, competence, integrity and respectful care had the lowest trust scores. Health centre operations predicted the local expressions of trust. The behavioural consequences of trust were limited to a positive statistical association with antenatal care uptake among pregnant women but outweighed by alternative measures that also captured the availability of healthcare facilities. Conclusions Overall, the development of our quantitative trust scale offers a process model for future researchers. We conclude that interpersonal, institutional and service-related trust require more explicit recognition in health system development and integration into health policy.

Biopolitics in Rebel- Controlled Myanmar: Exploring Why the United League of Arakan Supports the Kyaukphyu Special Economic Zone

In this article, we explore why the Myanmar-based insurgency organisation known as the United League of Arakan (ULA) supports the Kyaukphyu Special Economic Zone (KSEZ): a controversial Belt and Road Initiative (BRI) project. We argue that the

ULA’s support for the KSEZ is rooted in a biopolitics that benefits the ULA by attractively showcasing its insurgent aims and by effectively boosting its local authority. The ULA’s pro-KSEZ policy partially explains why the KSEZ, unlike other BRI projects in

junta-led Myanmar, has enjoyed moderate success. Despite its biopolitical benefits, the ULA’s pro-KSEZ policy has marginalised certain anti-KSEZ actors in the rebel organisation’s sphere of control. The resulting fragmentation may both destabilise the ULA’s hard-fought social order and undermine the prospects of the KSEZ. Our examination of the ULA–KSEZ relationship empirically contributes to BRI-in-Myanmar research, which has heretofore paid little attention to rebel-controlled societies’ significant influence on foreign-led domestic development projects.

The impact of conservation and land use transitions on the livelihoods of indigenous peoples: A narrative review of the northern Thai highlands

Ecosystem conservation has moved to the centre of global development agendas in light of an unprecedented acceleration of environmental degradation, species extinction, and catastrophic weather events. Global and national conservation policies with seemingly laudable aspirations, however, have been widely instrumentalised and distorted – leading researchers to argue that the very tools to safeguard natural spaces feed consistently into a market-oriented agricultural production and modernisation agenda. Indigenous peoples who continue to inhabit protected spaces as their ancestral lands have systematically suffered in this process. We conducted a place-based narrative literature review to formulate a consistent agenda for the next generation of conservation research and policy to help overcome this persistent challenge, drawing on the extensive and interdisciplinary research literature of the northern Thai highlands published until 2021.

The place-based narrative review traced gradual contextual change, inconsistent policy directions, and perverse incentives that have created a systemic challenge to ecosystem conservation. Key research gaps are the under-appreciated symbolic and affective dimensions of evolving tropical landscapes at the interface of Indigeneity, conservation, and development. Our proposed research agenda involves the synergistic combination of tools of human security, everyday environmental heritage, activity spaces, and behavioural design to understand these experiential dimensions of conservation from the perspective of Indigenous peoples, their active role as security contributors, pathways to impact, and new models of policy making. Suggested policy responses revolve around comprehensive domains of action (instead of isolated interventions) to overcome the systemic and contextual challenges affecting Indigenous livelihoods.

Explaining Challenges That Beset Transdisciplinary Projects in the Global South: The Shift from Methodological Perspectives to a Political- Economic Dynamic Analysis

In this paper, I argue that rigorous attempts to grasp the challenges unique to transdisciplinary projects in the Global South (TPGSs) require an understanding of the target state’s politicaleconomic dynamics, which can undermine TPGSs. In this regard, I harness social-conflict theory to examine how and why Cambodia’s political-economic dynamics affected my own transdisciplinary project, which addressed dam-induced problems in the northeast of the country from 2018 to 2021. The present paper’s findings clarify the relationships among various nonacademic TPGS stakeholders—a topic that has attracted little attention from transdisciplinarians but that can significantly shape TPGS

outcomes.

Shan Female Sex Workers’ Vulnerabilities and Coping Strategies in Response to COVID-19 in Chiang Mai, Thailand

The Thailand government has marginalized, criminalized, and discriminated against migrant sex workers for decades and the COVID-19 pandemic has only increased the vulnerability of sex workers to hardship. Using a mixed research methodology including interviews, this article outlines the risks Shan sex workers in northern Thailand faced during the COVID-19 pandemic that began in 2020, their vulnerability contexts, and their coping strategies, including how institutional aid and existing assets impacted their livelihoods. Our findings reveal that Shan sex workers in Thailand have suffered primarily from oppressive laws and social stigma. They were excluded from government COVID-19 mitigation measures such as health services, compensation, and economic support. Identifying vulnerability factors highlights the difficulties of both systemic and individual-level responses, leading to suggestions for policymaking to improve the quality of sex workers’ lives. This study reveals that Shan sex workers are still being left behind and discriminated against in Thailand, but they have persevered to speak their minds and struggle to live through the COVID-19 crisis. There is an urgent need for Thailand authorities to decriminalize sex work and restructure the social security system so that it is inclusive for migrants.

Turbaned Northern Thai-ness: selective transnationalism, situational ethnicity and local cultural intimacy among Chiang Mai Punjabis

Chiang Mai is home to approximately 400 diasporic Punjabis, some of whom are sixth-generation residents of Thailand. While their transnational orientation, distinct sartorial choices and cultural practices might present them as outsiders to essential Thainess, Northern Thai Punjabis transgress the national image of Thainess and subjectively consider themselves to be Northern (Lanna) Thais. At the same time, these Thai citizens avail themselves of Overseas Citizenship of India (OCI) status for privileged access to economic, cultural and educational resources in India. Based on 51 in-depth interviews and 17 focus group studies among resident Hindu, Sikh and Namdhari Sikh communities in Northern Thailand, this research explores family histories, selective transnationalism, and regional Lanna identities among these overseas Punjabis. As this article will argue, while Punjabi Thais maintain their networks and cultural connections with an historic ancestral homeland, they also cultivate forms of local cultural intimacy in ways which leapfrog the linguistic and cultural hegemony of Thai national identity.

Heterosexual Reading vs. Queering Thai Boys' Love Dramas among Chinese and Filipino Audiences

Over the past decade, Thai boys' love (BL) series,[1] which typically portray two young men as the focus of a love interest, have been a phenomenon throughout Asia. Originating from Japanese yaoi manga translated into Thai in the 1990s, the Thai BL genre has expanded from manga to novels, fan fictions, films and live action TV series. This paper focuses on Thai BL series whose stories depict homoromantic or homoerotic relationships between young male couples, which have become popular throughout Asia.Since its inception in 2014, enthusiastic fans in many different linguistic communities have worked to provide subtitles to BL content and helped to popularise Thai BL series. Thai BL actors have gained a large following among mostly heterosexual women, not only in Thailand but also in China, Japan, Vietnam, Malaysia, Indonesia, the Philippines, Taiwan and even Latin America.

Carnivalesque communities: Thai TV dramas and the Chinese censorship

This paper explores how Thai television dramas, which have been a staple of the nation’s TV landscape for many decades, have made new inroads in mainland China. Despite intense censorship by the Chinese state, China’s extremely large market enticed the Thai media industry. Control over what citizens can see on websites has also created an obstacle for which fan communities must find ways to bypass. The paper outlines both the historical process of Thai TV dramas’ inroads into the Chinese market and the different tactics Thai media companies and Chinese fan communities employ to circumvent Chinese state censorship. Based on interviews with various actors, including Thai TV media personnel, Chinese fansub groups, and fan communities, the paper argues that Chinese fan culture surrounding Thai TV series is a mixture of a subversive community that rebels against state control, as well as a constantly negotiating subculture that adopts various practices to break out from state censorship. Chinese youth today show that consumption is a site of contestation, rather than a site of control and manipulation.

ทบทวนอคติทางชาติพันธุ์ในปริมณฑลรัฐไทย

มุกดาวรรณ ศักดิ์บุญ. 2565. "ทบทวนอคติทางชาติพันธุ์ในปริมณฑลรัฐไทย" ในหนังสือ "ส่องอคติทางชาติพันธุ์." กรุงเทพฯ: ศูนย์มานุษยวิทยาสิรินธร. หน้า 104-125. 

หนังสือ ส่องอคติทางชาติพันธ์ุ 1 นี้ ได้รวบรวมบทความของนักวิชาการหลายท่านที่เสนอวิธีคิด การตรวจสอบ และแนวทางการวิเคราะห์ปัญหาอคติทางวัฒนธรรมในมิติต่าง ๆ อย่างกว้างขวาง ทั้งอคติที่สัมพันธ์กับความเป็นชาติ ศาสนา เชื้อชาติ ชาติพันธุ์ แรงงานข้ามชาติ อคติต่อคนไร้ที่อยู่อาศัย คนต่างรุ่นต่างวัย คนหลากหลายทางเพศ การกลั่นแกล้งกันในโรงเรียน อคติในยุทธศาสตร์และนโยบายของรัฐ การลำเอียงของสื่อมวลชน และการนำเสนอชีวิตของคนอีสานและเพศทางเลือกในภาพยนตร์ไทย คนเหล่านี้ล้วนเผชิญกับการดูหมิ่นเหยียดหยามด้วยคำพูด การล้อเลียนเสียดสีด้วยกิริยาท่าทาง การตีตราว่าร้าย และการประณามทางสังคม ที่เป็นการลดคุณค่าและศักดิ์ศรีของควมเป็นมนุษย์..."

Chinese Investor Networks and the Politics of Infrastructure Projects in the Eastern Economic Corridor in Thailand

This research examines Chinese investment and the impact of infrastructure projects on the Eastern Economic Corridor project (EEC), a special economic zone linking Thailand with Cambodia, Laos, Myanmar, Vietnam, and China, which aligns with the Belt and Road Initiative (BRI). Drawing on Actor Network Theory (ANT), this study analyzes emerging Chinese investor networks and the resulting negotiations between various actors such as the Thai state, Chinese and Thai investors, and local farmers. Many Chinese investors have moved their production bases to avoid the tax barriers raised by the United States or Europe, as well as to expand their markets in Southeast Asia. The Thai state offers tax benefits to foreign investors, allowing them to import raw materials and machinery from China, making their production costs lower than those of Thai investors. The findings reveal that the neoliberal state facilitates foreign investors through deregulation: enacting city planning laws that permit the establishment of industrial estates in agricultural zones, thus dispossessing farmers of their land. These factories can release toxic waste, thus impacting the local environment and livelihoods of nearby farmers. Thai business-people are often unable to compete with Chinese investors to match their bids. In order to maintain their positions in these economic networks, they build affective relations with Chinese investors. In addition, these affective relations attract resistance and indignation from locals dispossessed of land and resources.



Review of the Research on the Belt and Road Initiative in Myanmar

The Belt and Road Initiative (BRI) is among the largest transnational development initiatives globally. In this article, we review the research on the BRI in Myanmar, a developing country that is of considerable geopolitical importance. To date, the BRI literature has made three central contributions: it has captured much of the complexity of BRI projects, filled a notable research gap in BRI studies, and raised awareness of local voices. In addition, two analytically meaningful topics are worth exploring, namely the contested relations (1) between China’s Ministry of Foreign Affairs and prospective Chinese BRI investors and (2) between the Myanmar government and local anti-BRI groups. Responding to the current focus of the literature and to advance future research, we recommend that scholars consider the analytical framework of state transformation to disaggregate statehood, account for diverse actors, and explain their contested relations. Because it challenges state-centric frameworks (e.g., realism and Westphalian national sovereignty), the state-transformation model can yield theoretically and empirically stimulating findings.

Online publication: https://brill.com/view/journals/ejea/22/3/article-p229_2.xml

date: 14 Dec 2023

When the ‘Buddha’s Tree Itself Becomes a Rhizome’: The Religious Itinerant, Nomad Science and the Buddhist State

This paper considers the political, geo-philosophical musings of Deleuze and Guattari on spatialisation, place and movement in relation to the religious nomad (wandering ascetics and reclusive forest monks) inhabiting the borderlands of Thailand. A nomadic science involves improvised ascetic practices between the molar lines striated by modern state apparatuses. The wandering ascetics, inhabiting a frontier political ecology, stand in contrast to the appropriating, sedentary metaphysics and sanctifying arborescence of statism and its corollary place-making, embedded in rootedness and territorialisation. It is argued that the religious nomads, residing on the endoexteriorities of the state, came to represent a rhizomatic and politico-ontological threat to centre-nation and its apparatus of capture. The paper also theorises transitions and movement at the borderlands in the context of the state’s monastic reforms. These reforms, and its pervasive royal science, problematised the interstitial zones of the early ascetic wanderers in their radical cross-cutting networks and lines, moving within and across demarcated frontiers. Indeed, the ascetic wanderers and their allegorical war machine were seen as a source of wild, free-floating charisma and mystical power, eventually appropriated by the centre-nation in it’s becoming unitary and fixed.

Aligning global health policy and research with sustainable development: A strategic market approach

Attaining Sustainable Development Goal 3 (SDG 3: Health and Well-Being) faces a dual challenge of diminishing returns of established intervention designs, and a threat to future gains from complex inter-connected global health challenges like antimicrobial resistance and global biodiversity loss. The growing movement of contextsensitive approaches could help realise yet untapped potential for intervention designs, but contemporary global health policy and research still remain dominated

by a model of individual market style choices. This paper therefore aims to support the development of global health planning processes that are more grounded and integrative across the SDGs. Reiterating calls for disruptive policy change is unlikely

to impact the modus operandi of global health policy and research. This paper therefore builds on a logic that already finds widespread and intuitive application in their underlying planning processes: ‘the market’. However, it challenges the dominant

supply-and-demand approach to healthcare markets and redefines them from a strategic marketing perspective. Translated to the interface of populations and health systems, the strategic market is a site for solving problems that are defined by people

with multidimensional health needs. This framework offers four guiding questions to define the strategic market and six premises as a simple intellectual starting point and checklist for more grounded and inter-sectorial action across the SDGs. The analysis of data from one of the largest behavioural survey data sets, covering 6683 villagers across China, India, Lao PDR and Thailand, demonstrates the relevance of the premises empirically.

Community-level incidence and treatment seeking during febrile illness: Insights from health behaviour surveys in rural Thailand and Laos

Objective:

Critical gaps remain in understanding community perceptions and treatment-seeking behaviours in case of fever. This is especially relevant considering global antimicrobial resistance, where fever is assumed to provoke non-judicious antibiotic use. Our study objective was therefore to document the community-level incidence of fever, the resulting treatment-seeking processes, and their underlying behavioural drivers.

Methods:

In a cross-sectional observational design, we used descriptive and inferential statistics and multivariable regression analysis to estimate the population-level incidence of fever and individual and socio-economic factors associated with treatmentseeking process characteristics. We utilised a detailed publicly available survey of community-level treatment-seeking behaviour (collected in 2017/2018), comprising a representative sample of 2130 rural adults in Thailand (Chiang Rai Province) and Lao PDR (Salavan Province).

Results:

Fever was reported by 7.1% of the rural adult population in Chiang Rai (95% CI: 5.1%–9.0%) and 7.5% in Salavan (95% CI: 4.5%–10.5%) during a 2-month recall period. Treatment-seeking patterns varied by socio-economic characteristics like precarious employment. 69.3% (95% CI: 60.8%–77.7%) of fever episodes involved access to formal (public/private) healthcare providers, 11.0% (95% CI: 4.5%–17.5%) involved informal providers, and 24.3% (95% CI: 16.6%–32.1%) took place without either formal or informal healthcare access. Febrile patients had on average 0.39 antibiotic use episodes when accessing formal healthcare settings, compared to 0.05 otherwise (p < 0.01).

Conclusion:

Treatment-seeking behaviour during fever varies according to population characteristics. Clinical studies would benefit from contextualising quantitative outcomes. Treatment algorithms for non-malarial febrile illnesses should involve outreach to informal healthcare and community settings to support patients in precarious circumstances, and antibiotic resistance interventions should prioritise formal healthcare facilities.