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      Experiences of using life histories with health workers in post-conflict and crisis settings: methodological reflections

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          Abstract

          Introduction: Life history is a research tool which has been used primarily in sociology and anthropology to document experiences of marginalized individuals and communities. It has been less explored in relation to health system research. In this paper, we examine our experience of using life histories to explore health system trajectories coming out of conflict through the eyes of health workers.

          Methods: Life histories were used in four inter-related projects looking at health worker incentives, the impact of Ebola on health workers, deployment policies, and gender and leadership in the health sector. In total 244 health workers of various cadres were interviewed in Uganda, Sierra Leone, Zimbabwe and Cambodia. The life histories were one element within mixed methods research.

          Results: We examine the challenges faced and how these were managed. They arose in relation to gaining access, data gathering, and analysing and presenting findings from life histories. Access challenges included lack of familiarity with the method, reluctance to expose very personal information and sentiments, lack of trust in confidentiality, particularly given the traumatized contexts, and, in some cases, cynicism about research and its potential to improve working lives. In relation to data gathering, there was variable willingness to draw lifelines, and some reluctance to broach sensitive topics, particularly in contexts where policy-related issues and legitimacy are commonly still contested. Presentation of lifeline data without compromising confidentiality is also an ethical challenge.

          Conclusion: We discuss how these challenges were (to a large extent) surmounted and conclude that life histories with health staff can be a very powerful tool, particularly in contexts where routine data sources are absent or weak, and where health workers constitute a marginalized community (as is often the case for mid-level cadres, those serving in remote areas, and staff who have lived through conflict and crisis).

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          Most cited references 22

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          Mind in Society, the Development of Higher Psychological Processes

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            Interpretive Autoethnography

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              Living through conflict and post-conflict: experiences of health workers in northern Uganda and lessons for people-centred health systems

              Providing people-centred health systems—or any systems at all—requires specific measures to protect and retain healthcare workers during and after the conflict. This is particularly important when health staff are themselves the target of violence and abduction, as is often the case. This article presents the perspective of health workers who lived through conflict in four districts of northern Uganda—Pader, Gulu, Amuru, and Kitgum. These contained more than 90% of the people displaced by the decades of conflict, which ended in 2006. The article is based on 26 in-depth interviews, using a life history approach. This participatory tool encouraged participants to record key events and decisions in their lives, and to explore areas such as their decision to become a health worker, their employment history, and their experiences of conflict and coping strategies. These were analyzed thematically to develop an understanding of how to protect and retain staff in these challenging contexts. During the conflict, many health workers lost their lives or witnessed the death of their friends and colleagues. They also experienced abduction, ambush and injury. Other challenges included disconnection from social and professional support systems, displacement, limited supplies and equipment, increased workload and long working days and lack of pay. Health workers were not passive in the face of these challenges, however. They adopted a range of safety measures, such as mingling with community members, sleeping in the bush, and frequent change of sleeping place, in addition to psychological and practical coping strategies. Understanding their motivation and their views provides an important insight how to maintain staffing and so to continue to offer essential health care during difficult times and in marginalized areas.
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                Author and article information

                Affiliations
                [1 ]Professor of International Health Financing and Health Systems, ReBUILD and Queen Margaret University, Edinburgh, UK
                [2 ]Research Fellow, ReBUILD and Department of Health Policy, Planning and Management, Makerere School of Public Health, Kampala, Uganda
                [3 ]ReBUILD, Liverpool School of Tropical Medicine, Liverpool, UK
                [4 ]Health Systems Researcher, ReBUILD Consortium and College of Medicine and Allied Health Sciences, University of Sierra Leone, Freetown
                [5 ]Social Science and International Health, ReBUILD and RinGS consortia, Liverpool School of Tropical Medicine, Liverpool, UK
                [6 ]Institute of Development Studies, Sussex, UK
                [7 ]ReBUILD and Biomedical Research and Training Institute, Harare, Zimbabwe
                [8 ]ReBUILD and RinGS consortia, Cambodian Development Resource Institute, Phnom Penh, Cambodia
                [9 ]Public Health Researcher, ReBUILD and RinGS consortia, Biomedical Research and Training Institute, Harare, Zimbabwe
                [10 ]ReBUILD and Department of Health Policy, Planning and Management, Makerere School of Public Health, Kampala, Uganda
                [11 ]Rebuild and Liverpool School of Tropical Medicine, Liverpool, UK
                Author notes
                [* ]Corresponding author: Sophie Witter, Institute for Global Health and Development, Queen Margaret University, Edinburgh, EH21 6UU. Email: switter@ 123456qmu.ac.uk
                Journal
                Health Policy Plan
                Health Policy Plan
                heapol
                Health Policy and Planning
                Oxford University Press
                0268-1080
                1460-2237
                May 2017
                04 January 2017
                04 January 2017
                : 32
                : 4
                : 595-601
                28052985 5400054 10.1093/heapol/czw166 czw166
                © The Author 2017. Published by Oxford University Press in association with The London School of Hygiene and Tropical Medicine.

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited.

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                Pages: 7
                Product
                Funding
                Funded by: UK Aid, Department for International Development, under the ReBUILD research consortium
                Categories
                Methodological Musings
                Editor's Choice

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