Conceptual framework

The outputs of the literature review conducted in chapter 2 focusing on the concepts of FCC, together with a theoretical approach derived from critical medical anthropology (CMA) informed the development of the conceptual framework that guided this research (figure 4.1).

CMA is a school of thought that emerged in the late 1970s and came to prominence during the 1980s as an approach to understanding how health inequities are shaped by social and economic structures and institutions that create, enforce and perpetuate observable disparities in health (Morsy, 1979). The approach emphasizes “the importance of political and economic forces, including the exercise of power, in shaping health, disease, illness experience, and health care” (M. Singer & Baer, 1995). That is, its focus is on how the ‘sufferer’s experience” is shaped by political, economic and social forces, not just disease pathologies. Leading scholars of CMA such as Soheir Morsy and Hans Baer (M. Singer & Baer, 1995; Merrill Singer & Baer, 2011) offer a critique of biomedical and anthropological ecological and interpretive approaches to health disparities arguing that such approaches fail to take into consideration the impact of macro-level factors i.e. political and economic forces on the micro-level health and illness experience. In addition, just as in medical anthropology, they argue the organisation and management of health systems in many high and low-income countries are dominated by biomedicine which is itself a cultural system with sets of beliefs, rituals and power relationships that deserve the same critical analysis as any other cultural system (Singer and Baer 1995).

The CMA approach has evolved over the years and in the 1990s the term ‘structural violence1_{’ was introduced into CMA theory to help highlight how macro-influences shape} micro-level health outcomes (Farmer 1997; Scheper-Huges 1992). Farmer adopted the term to describe the inability of TB sufferers in Haiti to comply with treatment regimens; placing emphasis on their willingness to comply but describing how broader social, political and economic forces made it impossible for them to be able to comply with complex treatment regimens (Farmer 1997). Farmer has continued to apply this theory in his research on HIV/AIDS and more broadly, highlighting the connections between poverty and disparities in health care and outcomes (P. Farmer, 2003). Other authors who have adopted a CMA approach to health and used the term structural violence to describe inequities include Nancy Scheper-Hughes who used the term in her Brazilian study, examining mothering amidst everyday experiences of scarcity, sickness, and death (Nancy Scheper-Hughes, 1992). In this study she describes how mothers in this Brazilian village who live in these extreme conditions react to the sickness and death of their infants, thereby challenging the notions of ‘mother’s love’.

Using the CMA approach, I designed a conceptual framework that illustrates how the macro- structure of the social, political, cultural and economic context are important in shaping the philosophies of care and functional capacity of the health system, which in turn influences the paradigms of care and functional capacity of the study hospitals. The care paradigms are reflected in care structures (physical and organizational) of each hospital (Lassi, Middleton, Bhutta, & Crowther, 2016). These, together with the functional capacities of the hospital, influence caring in practice. In addition, the social, political, cultural and economic context shape community and family support mechanisms and the cultural norms of neonatal care which influence the micro-level practices of care of individual sick newborns (right-hand side of figure 4.1).

The study was undertaken using a CMA lens which requires recognition of macro-level factors influencing the micro-level health issues under investigation. The micro-level issue in my study was the ‘suffers experience’ - the individual experiences of mothers who had a sick newborn baby admitted as an inpatient in the study hospitals in Nairobi. That is, the focus for my data collection was the centre of the diagram (figure 4.1), the micro-level of practices of care within each newborn unit. To frame my analysis of these practices I drew

1 _{The term was first used by Johan Galtung in the 1960’s to describe how social structures, economic, political,}

religious and cultural factors situated at a macro level could potentially hinder individuals, groups, and societies from accomplishing their full potential or put them at risk of preventable suffering (Galtung, 1969).

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on the literature to identify the common basic tenets of FCC. These I identified as (i) dignity and respect (ii) participation (iii) collaboration; and (iv) information sharing. My study was concerned with exploring the practices of care in the NBUs of the study hospitals and critically analyzing how these practices are shaped by broader macro-level influences as well as their alignment with the tenets of FCC.

Figure 4. 1 conceptual framework

In addition to the CMA theoretical approach that guided the development of my conceptual framework and helped focus my analysis, in this analysis, I also drew on the works of Pierre Bourdieu particularly on his insights on forms of capital. In his theory of Capital, Pierre Bourdieu identifies three forms of capital of interest to my study, these are 1) Social capital, 2) Economic capital and 3) Cultural capital (Bourdieu, 1986). Social capital as explained by Bourdieu stands for social networks and social relationships that result in collective identities. He describes economic capital as money or assets owned by someone which gives them status in society. Lastly, cultural capital denotes what one has, and the knowledge possessed by an individual. Bourdieu further classifies cultural capital into; a) embodied-

which are the qualities of one’s mind or body and this denotes the skills and mannerism that are possessed by an individual. People from higher social class differentiate themselves from others by how they look and behave. b) Institutionalized -which are linked to one’s credentials or qualifications that may symbolize authority and c) Objectified-which are a person’s material belongings, the kind of material items that one owns, depending on settings can be a symbol of status, prestige and power (Bourdieu, 1986). All these forms of capital determine one’s social position in society. These forms of capital have been applied by researchers interested in understanding health inequities and in health research (Derose & Varda, 2009). Pinxten and Lievens applied these concepts of capital in their investigation of social inequalities in perceptions of mental and physical health in Belgium (Pinxten & Lievens, 2014).