cross case analysis in research

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Field Guide to Case Study Research in Tourism, Hospitality and Leisure

ISBN : 978-1-78052-742-0 , eISBN : 978-1-78052-743-7

Publication date: 22 June 2012

This section of the book comprises three chapters written by Oksana Grybovych, Susan Slocum, Ken Backman, Elisabeth Baldwin and Chris Ryan. The first two by Grybovych (2012) and Slocum, Backman, and Baldwin (2012) respectively report research processes related to specific projects, while the last seeks to provide an analysis associated with cross-case study research. By definition cross-case analysis relates to comparisons being made across different places, or of the same place across different times (a longitudinal analysis such as that by Gu & Ryan, 2008, 2011, in their studies of Shi Chi Hai Hutong in Beijing) or indeed of different places at different times, but related to each other by the commonality of a theme identified by the researcher.

Ryan, C. (2012), "Cross-Case Analysis – Introduction", Hyde, K.F. , Ryan, C. and Woodside, A.G. (Ed.) Field Guide to Case Study Research in Tourism, Hospitality and Leisure ( Advances in Culture, Tourism and Hospitality Research, Vol. 6 ), Emerald Group Publishing Limited, Leeds, pp. 497-499. https://doi.org/10.1108/S1871-3173(2012)0000006030

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Cross-case Analysis

• This course teaches cross-case analysis (Miles and Huberman, 1994) using NVivo
• You will learn the specificities of the method, type of research questions it answers, its different stages and the kind of results it generates
• This course can be taken as a standalone unit or combined with another methodological seminar, any of the method courses or an NVivo course.

Description Cross-case analysis is a method that involves the in-depth exploration of similarities and differences across cases with a view to supporting empirical generalisability and theoretical predictions. We start with a definition of cross-case analysis and the objectives it pursues, then review the most common proxy terms in the literature and the type of research questions suitable to this approach. In NVivo we conduct the first stage of cross-case analysis — within-case analysis — using the conceptually clustered matrix. We then review coding procedures, using empirical examples to illustrate the benefits of working with descriptive, interpretive and pattern codes when formulating generalisations within cases. In the second part of the course, for the cross-case analysis, we use a case-ordered meta-matrix to search for similarities and associations across case outcomes. We then begin forming general explanations that we map on scatterplots. When empirically possible, cases are ordered by type, causal relationships between variables are explained and theoretical predictions are made using devices such as predictor-outcome matrices and causal models. We conclude with a critical appraisal of the methodological quality of studies that used cross-case analysis and the best data visualisations to present its findings.

Prerequisites Although no previous knowledge of any of the four methods of qualitative data analysis is required, participants should have some familiarity with qualitative research.

Schedule Half-day from 9:00 to 12:00 or full-day from 9:00 to 16:00.

Location This course is taught online in Zoom as well as onsite on a request basis.

Teaching methods Lectures, demos with NVivo and hands-on exercises.

Fee Please email me for information on fees.

Combining courses This course is part of a five-course series on methods of qualitative analysis that includes Methods of Qualitative Data Analysis, Qualitative Content Analysis, Thematic Analysis and Grounded Theory. It can be taken alone or in conjunction with the other related courses. It can also be taught before, after or simultaneously with the Introduction to NVivo or Qualitative Data Analysis with NVivo courses.

Related courses

Methodological seminars

Foundations to qualitative analysis

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7 Within-Case versus Cross-Case Causal Analysis

• Published: September 2012
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This chapter examines how the qualitative and quantitative research traditions treat within-case analysis versus cross-case analysis for causal inference. In qualitative research, the primary focus is on specific events and processes taking place within each individual case. Leading qualitative methodologies of hypothesis testing, such as process tracing and counterfactual analysis, are fundamentally methods of within-case analysis. By contrast, quantitative research traditionally involves exclusively cross-case comparison. The chapter begins with a comparison of the typical roles (or nonroles) of within-case and cross-case analysis in case studies versus experiments. It then considers how causal inference in quantitative and qualitative research is linked to the use of “data-set observations” and “causal-process observations,” respectively. It also explains the differences between process-tracing tests and statistical tests and concludes by suggesting that cross-case analysis and within-case analysis can and often should be combined.

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• DOI: 10.1108/S1871-3173(2012)0000006033
• Corpus ID: 59068382

Cross-Case Analysis

• Published 22 June 2012

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Simpson A, Hannigan B, Coffey M, et al. Cross-national comparative mixed-methods case study of recovery-focused mental health care planning and co-ordination: Collaborative Care Planning Project (COCAPP). Southampton (UK): NIHR Journals Library; 2016 Feb. (Health Services and Delivery Research, No. 4.5.)

Cross-national comparative mixed-methods case study of recovery-focused mental health care planning and co-ordination: Collaborative Care Planning Project (COCAPP).

Chapter 5 results: cross-case analysis.

• Summary of chapter

In this chapter, we conduct a comparison across the six sites. The chapter is in three sections. Section 1 contains cross-case analysis of scores on the quantitative measures. In Section 2 we draw on the within-case analysis of the qualitative data presented in the previous chapter and focus on four key areas: local context and developments; CPA/CTP care planning and co-ordination; recovery; and personalisation. Section 3 ends the chapter with tables identifying potential facilitators and barriers to the delivery of recovery-focused, personalised care planning and co-ordination. These are then discussed in more detail in Chapter 6 .

• Section 1: cross-case analysis of the quantitative data

Inferential statistics were used to determine if there were any differences across sites for the three questionnaires. Cross-site analyses will be presented for the three service-user questionnaires (the RSA scale, STAR-P and ES) followed by a cross-site analysis of the care co-ordinator questionnaire (the RSA scale). In addition, several correlations were conducted to determine associations between the questionnaire subscales and totals globally and on a site-specific basis.

Service users

One-way ANOVAs of all subscales were conducted and subsequent Tukey’s post-hoc tests demonstrated some areas of significant differences between research sites on the STAR-P measure of therapeutic relationships. There were significant differences across sites in the mean total STAR-P score [ F (5,429) = 3.45; p -value = 0.005], the positive collaboration subscale [ F (5,426) = 3.75; p -value = 0.002] and the positive clinician input subscale [ F (5,431) = 2.80; p -value = 0.017]. There are no global differences across the sites for the RSA scale and ES. Table 39 shows the mean item scores, alongside the parameters of significance.

Summary score statistics for the service-user responses to the RSA scale, STAR-P and ES

Burgundy in particular performs well on the STAR-P scale ( Figure 4 ). If Burgundy is used as a reference site, other research sites may be considered in relation to this. Languedoc also performs well on the perceived therapeutic relationship; however, Provence and Dauphine do not perform as well on this scale. Tukey’s post-hoc tests revealed that service users in Burgundy (38.49 ± 8.55) score higher on the mean total STAR-P than those in Provence (32.33 ± 11.91; p -value = 0.003). Burgundy also performs particularly well in comparison to perceptions of therapeutic relationships in Dauphine; however, this does not reach statistical significance (33.53 ± 9.23; p -value = 0.056).

Mean positive collaboration subscale score for service users ± 95% confidence interval. Scoring range for the scale from 0–24. ** p -value < 0.01.

Subscales of the Scale to Assess the Therapeutic Relationship

Tukey post-hoc tests revealed that service users in Burgundy (19.81 ± 6.57) score higher on the ‘Positive Collaboration’ subscale than those in Provence (16.15 ± 6.57; p -value = 0.002) and Champagne (17.13 ± 5.79; p -value = 0.062); however, this does not reach significance. There were no significant differences between Burgundy and the other sites on this subscale. Figure 5 shows the mean positive collaboration subscale with Burgundy as a reference site to the other sites.

Mean total STAR-P score for service users ±95% confidence interval. Scoring range for the scale from 0–48. ** p -value = 0.01.

Further Tukey post-hoc tests revealed that responses on the ‘Positive Clinician Input’ subscale are different across the research sites. The reference site, Burgundy (9.46 ± 2.45), performs significantly better than Provence (7.83 ± 3.49; p -value = 0.012) and Champagne (8.01 ± 3.05; p -value = 0.45). Burgundy and Champagne are the two Welsh research sites, which suggests that the differences within this subscale may be appearing at a local level rather than as a result of macro-level policy and the implementation of CTP and processes surrounding it ( Figure 6 ).

Mean positive clinician input subscale score for service users ± SEM. Scoring range for the scale from 0–12. ** p -value < 0.01.

Care co-ordinators

One-way ANOVAs were conducted for the mean RSA total score and the five RSA subscales for the care co-ordinators ( Table 40 ). There was a significant difference between the research sites in the ‘Choice’ subscale [ F (5,195) = 3.40; p -value = 0.006]. There were no significant differences found in the mean total RSA score and the other four subscales; however, the ‘Diversity of treatment options’ subscale was approaching significance [ F (5,195) = 2.10; p -value = 0.068].

Summary score statistics for the care-co-ordinator responses to the RSA scale, STAR-P and ES

When using Dauphine as the reference site (the site with the lowest score on this subscale), it is apparent that other sites are performing significantly better around the subscale of ‘Choice’ ( Figure 7 ).

Mean item response ‘Choice’ subscale score for care co-ordinators ±95% confidence interval. Scoring range on a scale of 1–5. * p -value < 0.05, ** p -value < 0.01.

This scale measures some important perceptions that may have a significant effect on patient outcomes, concordance to care and collaboration with clinicians. Subsequent Tukey’s post hoc revealed that service users in Dauphine (3.46 ± 0.68) score significantly lower on the subscale than Languedoc (4.04 ± 0.50; p -value = 0.008) and Burgundy (3.92 ± 0.65; p -value = 0.041). There were no significant differences between Dauphine and the other sites on this subscale. A summary table for the five highest scoring items on the RSA scale for each site is included in Table 41 for the service users and Table 42 for the care co-ordinators.

Summary table for the five highest rated items on the RSA scale by service users

Summary table for the five highest rate items on the RSA scale by care co-ordinators

Adjusted analysis

The advantage of using unadjusted ANOVAs to examine the data is that this retains the maximum number of participants in the analysis; the disadvantage is that case-mix differences between the sites could potentially bias the findings. In contrast, the strength of using ANCOVAs is that they adjust for the potential confounders but this is achieved at the cost of losing participants in the analysis owing to missing data on the covariates. This reduces the statistical power of the analysis and changes the composite of the sample, which poses a problem for the interpretation. Analysing the data using unadjusted and adjusted analyses offers a check on the robustness of the original (unadjusted) findings.

The ANOVAs reported above are not adjusted for potential confounders (i.e. variables that are potentially associated with the outcome variables and which may be differentially distributed across sites). For service users, three demographic variables (age; gender; ethnicity) and two care-related variables (relationship status; time in mental health services) were identified as potential confounders. These variables were used as covariates in a series on ANCOVAs to determine whether or not they substantively change the findings from the unadjusted analyses. For care co-ordinators, three demographic variables (age, gender and ethnicity) and two measures of clinical experience (time working in mental health services and time as a care co-ordinator) were identified as potential confounders for a further series of ANCOVAs. To determine whether the adjusted findings were different from the original findings, we compared the p -values for the omnibus ANOVA/ANCOVA, the p -values for the post-hoc comparisons, and the unadjusted and adjusted means for each scale and subscale for each site.

For the service users there were no substantive differences in the adjusted analysis for any of the subscales or the total scores of the RSA scale and the ES. Similarly, there were no substantive differences for two of the three STAR-P subscales or the total STAR-P score. However, for the ‘Positive clinician input’ subscale of the STAR-P there were minor differences in the adjusted means and this resulted in the difference between Burgundy and Champagne becoming non-significant ( p -value = 0.285). The observed difference between Burgundy and Provence in the unadjusted analysis remained significant in the ANCOVA ( p -value = 0.040).

Overall, the ANCOVA analyses for service users show that, although there were marginal changes in the adjusted means, these changes were not substantive and did not affect the overall pattern of findings. Consistency between the adjusted and unadjusted analyses suggests that the findings are robust.

For the care co-ordinators, two of the five subscales of the RSA scale suggested no substantive differences in the adjusted analysis. However, for the ‘Choice’ subscale, some previously non-significant post-hoc comparisons become significant in the adjusted analyses. Figure 8 shows that the difference between Burgundy and Dauphine and the difference between Languedoc and Dauphine remained significant, but, in addition, Burgundy (4.00 ± 0.12) and Languedoc (4.07 ± 0.14) were now also significantly different from Provence (3.44 ± 0.14) ( p -value = 0.034 and p -value = 0.024, respectively). As the graph shows, these new differences emerged because the adjusted mean for Provence was marginally reduced and became closer to the reference site of Dauphine. It should be noted that the changes in the means are marginal and that the overall pattern of findings remains essentially the same.

Adjusted mean item response on Choice subscale score for care co-ordinators ± 95% confidence interval. Scoring range on a scale of 1–5. ** p -value < 0.01. a, identifies a significant difference compared with Dauphine; (more...)

For the total RSA score, changes in the adjusted means resulted in an emergent significant difference between Dauphine (2.99 ± 0.14) and Languedoc (3.65 ± 0.13; p -value = 0.019) ( Figure 9a ). For the ‘Diversity of treatment options’ subscale the difference between Dauphine (2.84 ± 0.86) and Burgundy (3.24 ± 0.78) became statistically significant ( p -value = 0.035) ( Figure 9b ). For the ‘Life goals’ subscale, the differences between Dauphine (3.21 ± 0.15) and two other sites also became significant: Languedoc (3.92 ± 0.14; p -value = 0.024) and Champagne (3.86 ± 0.13; p -value = 0.029) ( Figure 9c ).

Adjusted mean scores for care co-ordinators ± 95% confidence interval. (a) RSA total score; (b) diversity of treatment options; and (c) life goals subscale. * p -value < 0.05.

In terms of statistically significant differences between sites, the findings for care co-ordinators changed more than the findings for the service users in the adjusted analyses. Proportionally, the observed number of changes in significance was small compared with the number of post-hoc comparisons conducted, and changes in significance were predicated on relatively small absolute changes in the adjusted means across the various sites and outcome measures. The vast majority of the post-hoc comparisons did not change in terms of statistical significance in the adjusted analyses. The findings from the ANCOVAs therefore are suggestive of potential site differences on particular measures between specific sites, but these findings should be interpreted cautiously as there were no specific a priori hypotheses about site differences, and the loss of participants as a result of missing data on the covariates changes the sample composition.

Correlations between the outcome measures

Pearson’s correlations were completed at the global level with all participants to determine if there were associations between the responses on the questionnaire scales. Table 43 shows that there is a strong positive correlation between the RSA scale and the STAR-P ( r  = 0.61, N  = 409; p -value < 0.001). There is an association between the recovery-oriented focus and ratings of the quality of therapeutic relationships among service users. There is a weak relationship between the RSA scale and ES and a negligible relationship between the STAR-P and the ES.

Correlation analysis of the service-user responses to the outcome scales (all sites)

To explore the pattern of the higher correlation between the RSA scale and STAR-P, subsequent correlations were completed at the subscale level. There were positive associations found between the ‘positive collaboration’ and ‘positive clinician input’ subscales and the five RSA subscales ( Table 44 ). There were small to medium correlations between the ‘non-supportive clinician input’ subscale and the five subscales of the RSA scale. This is expected, as this subscale is a negatively framed subscale and, therefore, it is less likely to correlate with the RSA scale.

Subscale analysis of the RSA scale and the STAR-P (all sites)

Although it appears that these questionnaire scales have a strong positive correlation, the results should be interpreted with caution. There is the possibility that a ceiling effect in the data may have negatively skewed the data. When assessing the correlations by trust/health board it is apparent that there is some variability ( Table 45 ).

Correlation analysis of the service-user responses to the outcome scales (by site)

The RSA scale and STAR-P demonstrate the strongest and most consistent correlations compared with the overall analyses. There is, however, some variability across sites. All correlations demonstrate at least medium effects, and most are classed as large effect sizes.

With the RSA scale and ES, the sites are demonstrating greater variability, with some sites showing medium effects (Dauphine, Languedoc and Provence) and other sites showing smaller effects (Champagne and Artois); one site shows no relationship (Burgundy). The discontinuity across these sites suggests that some of these scales are behaving differently across the sites; however, further exploration of this is beyond the scope of this report.

The STAR-P and ES show less variability, with all sites showing a small to moderate association.

• Section 2: cross-case analysis of the qualitative data

The following is a narrative summary of the cross-case analysis of the interview data. Tables charting summaries of the within-case analyses, allowing cross-case comparisons, are available in Appendix 11 .

Local context and developments

Across all six sites there was an acknowledgement that services had been or were still undergoing a significant process of restructuring. The nature and impact of this period of flux appeared to vary, in particular between the two countries but also in relation to the integration of health and social care. Overall, there appeared to be moves towards greater integration of health and social care staff within teams, with colocation of NHS and LA personnel. Staff in Provence in particular stressed the strong shift towards generic mental health roles. Languedoc appeared to be moving in a different direction, with social workers being removed from CMHTs to focus on social care assessments and personal budget applications. This reportedly led to higher workloads within CMHTs and lower morale; this was also the only site in which medical domination of services was cited as an issue. Greater uncertainty about developments seemed to be expressed where more adventurous, wide-ranging restructuring had taken place, such as in Provence, where services were being centralised and teams now worked across age groups. This was accompanied by strongly articulated recovery-focused values, but there were acknowledgements by senior staff that staff morale had been hard hit by the upheaval, and the anticipated gains remained uncertain.

Development of new services in primary (e.g. primary care liaison roles) and secondary (setting up or merging of assertive outreach or crisis teams with CMHTs) care were reported, often alongside concerns over the impact of cuts in budgets, reductions in social care services and the challenges of providing continuity of care and effectively managing risks across an increasing range of third sector providers under the ‘any provider’ legislation in the Health and Social Care Act 2012. 131

In the two Welsh sites, the Mental Health Measure was clearly a strong driver for developments with senior managers and practitioners in both Burgundy and Champagne extolling its virtues, although the impact on everyday practice was less clear. Integration of health board and LA managers and teams was high on the agenda, although integration in the Champagne site appeared to be frustrated by continuing differences at the most senior levels and the absence of shared and accessible IT systems. Similar frustrations with IT were articulated across all sites.

Often strong commitments to the recovery agenda on all sites appeared to be frustrated by seemingly contrary policies (e.g. CTOs) and the related administrative demands; high acuity, high demands on services, high caseloads and the inadequacies and/or inflexibility of IT systems. Moreover, other organisational targets were skewing care co-ordination work, with recovery being interpreted as through-put and discharge, targets for PbR, personal budgets and organisational prioritising of particular types of support all working to standardise rather than personalise care or place recovery at the centre of things.

Care planning and co-ordination

The core aspects of the CPA were simply and straightforwardly expressed by senior managers and practitioners in terms of assessment, care plan, care co-ordinator and regular reviews. However, there appeared to be greater difficulty in articulating the implementation of the policy. There were major challenges in trying to make the CPA meet the very different needs of service users, practitioners, managers and commissioners. It continues to be administratively heavy and is insufficiently oriented towards recovery. There was widespread reporting of and often dissatisfaction with changes to documentation and some lack of clarity over CPA eligibility. In England, there were some concerns that the introduction of clustering and PbR was resulting in care plans being less individualised (Artois, Dauphine, Languedoc).

In Wales, the Measure was seen as very important, but there was no consensus on its actual impact. Views regarding the CTP were more mixed. In both sites, it was agreed that the All Wales CTP provides the structure or a framework to work within, but it was seen by some as reductionist. In Burgundy, it was claimed that not all psychiatrists used the CTP.

The introduction of electronic CPA documentation appeared to bring some benefits in terms of accessing and sharing information, but it also brought unwieldiness and a greater distancing from service users, as working collaboratively with people on care plans in their homes became more difficult. The solution, paradoxically, may lie in the development of more integrated IT systems and the use of modern, mobile technology.

Care co-ordinator caseloads reportedly ranged from 25 (Artois) to 40 or more (Champagne, Dauphine, Languedoc) or even 50 (Provence), and in most sites these were increasingly attributable to growing demands and tighter staff budgets. The care co-ordinator role was now held by any mental health professional, most often mental health nurses, social workers and OTs, less often psychologists, and rarely psychiatrists. Artois now also employed ‘non-professional’ staff (on Band 4) as care co-ordinators, with some concerns being expressed following incidents.

The care co-ordinator role was seen as a ‘generic’ role, with staff taking on increasingly similar co-ordinator duties, but one that was also complex, carrying significant responsibilities and often tasked with delivering most of the direct care. However, this genericism contained a tension when allied with capacity pressures within teams and attempts to allocate care co-ordinators to service users based on degree of fit. The desire to be responsive and provide a more personalised approach to care co-ordination was often frustrated by the lack of capacity within a team’s or individual’s caseload. Hence, a newly referred service user that might benefit from social worker input as s/he has predominantly social care needs is allocated a mental health nurse as care co-ordinator. The co-ordination tasks are similar but the therapeutic or supportive interventions are shaped, and at times limited, by the disciplinary background of the co-ordinator. There were widespread calls for more training on the CPA and specifically for care co-ordinators.

Efforts to increase the involvement of carers were mentioned occasionally (Dauphine), but more often it was the challenges and continuing tensions around issues such as service users’ consent and confidentiality that were mentioned (Artois, Languedoc), or uncertainty around how to involve people (Burgundy). There were varied experiences of care planning and care co-ordination from the viewpoints of service users, carers and care co-ordinators across all six sites, with no distinct differences identified. At best, care is planned in a structured and collaborative way with clear communication and opportunities for service users to influence and feel some ownership of the process. At worst, service users say that they feel cast aside, not involved, or that their care is planned as an obligatory task and in ways that are confusing and rigid.

Care co-ordinators are sometimes more positive about care being planned in individualised, collaborative ways than are service users and carers. They tend to welcome collaboration, but some also worry over how to address differences in view or believe strongly that some service users, particularly those with longer contact with services, are unwilling or unable to engage in such a process.

Risk was consistently seen as central to the CPA/CTP process by senior staff across all six sites. Similarly, safety and risk were paramount for care co-ordinators, but service users and carers were hardly involved in the assessment of these and many care co-ordinators expressed concerns over sharing their views, or those of their colleagues, around issues of risk. Service users and carers were often unaware of risk assessments being documented. Perhaps as a consequence, some service users and carers are largely unaware of risk management taking place and can feel that risk is not managed sufficiently or proactively. Risk aversion limits positive risk-taking and sits at odds with recovery ideals and practices.

Care plans are useful for staff and are recognised as having to be created; they have value as records of what has been decided and for including contact details and, sometimes, crisis and contingency plans. For a handful of people care plans are like a contract. But, for the majority of people, care plans are not highly valued and are not seen as active documents; many people (care co-ordinators and service users included) do not routinely refer to care plans once they have been created. Many service users do not have care plans, or have received and quickly discarded them. Others file them in a drawer, never to look at them again. Interestingly, care co-ordinators often thought that care plans were difficult to understand, but most service users did not agree; they just thought that they were of limited utility. Some care co-ordinators mentioned the development of first person care plans but service users rarely, if ever, mentioned this. There is clearly a tension between standardisation of documentation and individualised approaches to care planning. There was some, but not much, evidence of care planning addressing service users’ strengths and accomplishments.

As has been reported previously, care co-ordinators find care planning and care co-ordination administratively burdensome and complain that they have insufficient time for face-to-face work with service users and their families. Therapeutic relationships, however, are seen as very important; along with the care co-ordinator’s skills and knowledge of the service user. Service users and carers want to see more of their care co-ordinator and recognise discontinuity (e.g. when care co-ordinators leave or when there is organisational change) as a barrier to good care. There is no clear appetite for electronic care plans: service users and care co-ordinators repeatedly reported that current IT systems (which are often incompatible within sites, and between NHS and LA services) are frequently inflexible and a hindrance to collaborative care planning.

Carers have varied experiences within sites, but many are not engaged with care planning and co-ordination. Some do not see this as problematic, instead seeing it as something that occurs primarily between the service user and their care co-ordinator.

Surprisingly little was said about review meetings, although experiences varied; at best these meetings are collaborative, with good preparation and involvement of the service user and others. Often, care co-ordinators described difficulties arranging multidisciplinary involvement and ad hoc meetings with perhaps just the service user and psychiatrist.

Across all sites, the lack of sufficient staff, resources and time to work more collaboratively with service users and carers was reported by care co-ordinators.

Among senior personnel there was some clear articulation of what recovery and recovery-focused values might be, but varying degrees of sign-up to recovery and frequent talk of resistance among some staff. In Languedoc, for example, there was a broad understanding and evidence of a Recovery College, co-produced care plans and some use of recovery tools (e.g. Recovery Star, WRAP) but a reported lack of passion among senior managers, and conservative medical staff content to retain more traditional approaches. Similar resistance among medical staff and some older nursing staff was also reported in Provence, alongside a belief that ‘not all service users will recover’. Nonetheless, managers in Provence also cited the introduction of peer workers and greater use of ‘recovery language’.

In Artois, recovery was seen as a ‘bridge between medical and social models’ and also something ‘we have always been doing’. It was also seen as being about discharging service users reluctant to move on. Barriers to the implementation of a greater focus on recovery in Artois included the need for more staff, more time, improved IT systems and a stronger organisational commitment.

Senior staff in Dauphine acknowledged that the move towards recovery had been fairly recent and had been met by some resistance among some staff, and that the CPA alone ‘was enough’. However, there was a drive to increase the use of personal budgets, and help with obtaining employment was much more commonplace. Some recovery-focused tools were being introduced (Artois, Languedoc), but this was much less clear elsewhere (Burgundy, Champagne, Dauphine, Provence).

In Wales, the Measure had placed recovery high on the agenda for senior staff, with good understandings of recovery seen in Champagne but more mixed understandings of recovery expressed in Burgundy. For some in Champagne, the CTP did not have a clear focus on recovery and it was felt that greater training was needed for both staff and service users to bring about a change in culture.

More training around recovery working and the use of recovery tools, and perhaps a better understanding of the new ways of working to deliver recovery-focused care, were suggested for both staff and service users (Champagne, Dauphine).

As with care planning, service users, carers and care co-ordinators had varied views and experiences in relation to recovery across all sites, with the term itself often having different meanings for different people. Different views between professional groups were also mentioned. For some care co-ordinators it was even seen as unhelpful or deceptive, as it appeared to be more about discharging service users from caseloads. Across sites, many service users used terms commonly found in recovery literature, such as choice, independence, hope, fulfilment; but, for many, recovery is primarily about managing and coping better with their illness. Very few talked about recovery as a ‘journey’.

There were no clear views that care planning helped recovery, unless care plans included practical steps or helped service users to accept or talk about their mental health. Some service users and carers said that strengths were acknowledged. For service users and carers in particular, conversations and relationships, along with families and friends, were identified as being far more important than care plans in promoting recovery.

Even within single sites there is variable use of, experience in, and enthusiasm for recovery tools. At best, WRAPs are seen as very personalised and helpful, but some care co-ordinators worry about the extra work required. Some care co-ordinators say they have always worked in a recovery-focused way, and what hindered them were organisational targets and issues such as adversity to risk, documentation, limited resources and ‘firefighting’. There were also the challenges of negotiating over sometimes competing views between service users and care co-ordinators on achievable progress and managing medication side-effects, which can seriously impair recovery.

Personalisation

Across the case-study sites, personalisation was not understood as consistently as the concept of recovery among senior personnel, and definitions tended to include person-centred care plans and the use of first-person terminology in care plans (Artois); placing the person at the heart of social care (Artois); and the use of personal budgets (Artois, Dauphine) and direct payments (Champagne).

In relation to personal budgets, there was a clear lack of uniformity and this was also the one area where there was a marked difference between the two countries, perhaps reflecting the different policy emphases. Some sites saw the use of personal budgets as a key tool in the move towards a focus on recovery and personalisation of care (e.g. Dauphine, Languedoc, Provence). In both sites in Wales, there was much less emphasis on the use of personal budgets, which were seen very much as part of a creeping ‘marketisation’ of health care and, as a consequence, were subject to more resistance and a more limited move towards the use of direct payments (Champagne).

Even where personal budgets were promoted, it was recognised that they were accompanied by extremely heavy administrative loads, which took practitioners away from face-to-face contact with service users and their families (Artois, Dauphine, Languedoc). There were also often severe delays in actually receiving funds, which impacted on service users and staff (Dauphine). Elsewhere, service users often failed to meet the strict approval criteria against which they were judged, or were reluctant to make a contribution (Languedoc). Senior staff also spoke of there being tensions when service users were unwell and suggested that talk of a more personalised approach could ‘raise expectations’ that could not always be met (due to tight budgets and restricted local services and options) (Champagne).

There was also an articulation of some of the tensions that exist in the supposed move towards greater personalisation, with CTOs (Artois) and clustering cited as a counterpoint (Dauphine). Being able to purchase services from any provider also increased difficulties around sharing information and issues of confidentiality (Dauphine). Uniquely, in Languedoc, under an agreement made under Section 75 of the National Health Services Act 2006 between the LA and the trust, social workers were removed from CMHTs to focus on assessments and processing of direct payments and personal budgets. 132 The aim was to increase the move towards the use of personal budgets by service users to purchase care and support, which was seen as a key tool in the move towards personalisation of services. It appeared that, although the success of this approach was still to be determined, the impact on remaining staff within CMHTs was less than positive, with caseloads and workloads increasing with the loss of the social workers from the teams.

Commissioners of services in Provence also saw personal budgets as key drivers towards greater self-directed support. The Trust had exceeded initial targets, but senior staff spoke of the significant administrative burden. Staff also needed to develop new skills and understanding to negotiate with providers. Concerns had also emerged about the potential increased risk when dealing and communicating with multiple providers following recent serious incident enquiries. Nonetheless, personal budgets were now being used widely, according to senior managers and practitioners.

Among service users, carers and care co-ordinators, personalisation was understood in very different ways across sites. Often it was equated with individualised care, choice, service user-led services, tailoring care, and balancing structure and flexibility. More specifically, it was used to refer to new practices: personal budgets and direct payments. A number of people in all sites had no idea what personalisation is about.

Service users and carers variously described care as being personalised, or as very much not personalised, depending on personal experiences, with no distinct differences between sites emerging. Some service users saw their care plans as very personalised, others most definitely did not. Similar feelings were expressed by carers. Personalisation was constrained by lack of resources and availability of local services, by service users not always being aware of the options available to them, and by service users deferring to professionals. Gaps were observed between the ideal and the reality, with staff reporting high administrative workloads and the complexity of actually accessing and using personal budgets. As with recovery, some care co-ordinators reported that personalisation can raise unrealistic expectations.

It was also apparent that services across sites often allocate care co-ordinators to service users on the basis of caseload space rather than appropriateness, further challenging personalised relationships or more personalised approaches to strengths, interests and goals. In terms of personalisation, care planning and co-ordination it was not clear that personalisation can be achieved consistently using current templates and approaches.

• Section 3: potential facilitators and barriers to the delivery of recovery-focused, personalised care planning and co-ordination

This chapter ends with two tables in which we draw on the detailed within-case and cross-case analyses above to identify potential facilitators and barriers to the delivery of recovery-focused, personalised care planning and co-ordination ( Tables 46 and 47 ). These are discussed in more detail in Chapter 6 .

Facilitators to recovery-focused, personalised care planning and co-ordination

Barriers to recovery-focused, personalised care planning and co-ordination

Included under terms of UK Non-commercial Government License .

• Cite this Page Simpson A, Hannigan B, Coffey M, et al. Cross-national comparative mixed-methods case study of recovery-focused mental health care planning and co-ordination: Collaborative Care Planning Project (COCAPP). Southampton (UK): NIHR Journals Library; 2016 Feb. (Health Services and Delivery Research, No. 4.5.) Chapter 5, Results: cross-case analysis.
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Internalized stigma and its correlates in families of persons with mental illness in Qatar: a cross-sectional study

• Open access
• Published: 16 September 2024

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• Vahe Kehyayan   ORCID: orcid.org/0000-0002-2462-7399 1 ,
• Hanin Omar 2 ,
• Suhaila Ghuloum   ORCID: orcid.org/0000-0002-1384-4179 3 ,
• Tamara Marji 4 ,
• Hassen Al-Amin   ORCID: orcid.org/0000-0001-6358-1541 5 ,
• Muna Abed Alah   ORCID: orcid.org/0000-0003-3091-9483 6 &
• Ziyad Mahfoud   ORCID: orcid.org/0000-0003-4098-6401 5  

Persons with mental illness (PWMI) experience rejection, isolation, and discrimination in employment, education, and housing due to the prejudice associated with the illness. Families affiliated with PWMI often internalize the public’s prejudice towards mental illness. Such internalized stigma can further impact the health and quality of life of both PWMI and their families. This study aimed to examine the level and correlates of internalized stigma in family members of PWMI in Qatar. A cross-sectional study of 106 family members was conducted using the Family Internalized Stigma Mental Illness Scale. The mean stigma score was 2.04 suggesting a mild level of stigma overall. Being married was found to be a predictor of higher levels of internalized stigma, while having college education or higher predicted lower levels of stigma. The overall stigma scores among family members were not high, which may reflect the protective stance families take towards about their relatives with mental illness. Some sociodemographic attributes predicted trends in internalized stigma among our surveyed sample. Future research efforts in this area may help increase understanding of internalized stigma in this population to inform stigma reduction efforts.

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Introduction

Stigma associated with mental illness is prevalent globally, affecting individuals with mental illness (PWMI), the general public, and healthcare professionals, leading to adverse outcomes for PWMI and their families (Krajewski et al., 2013 ; Kronfol, 2012 ; Parcesepe & Cabassa, 2013 ; Pescosolido et al., 2013 ; World Health Organization, 2013 ). Several definitions of stigma have been offered in the literature. Goffman, a sociologist, defined it as “an attribute that is deeply discrediting and that makes the person different from others and of a less desirable kind, and motivate efforts by the stigmatized individual to hide the mark when possible” (Goffman, 1986 ). An alternate definition was given by the World Health Organization (WHO), “A mark of shame, disgrace, or disapproval that results in an individual being rejected, discriminated against, and excluded from participating in a number of different areas of society” (WHO, 2001 , p. 16) (World Health Organization, 2001 ). Despite the lack of consensus on its definition, it is generally accepted that stigma is a subjective and multifaceted concept, as people’s experiences with it are shaped by their cultural beliefs and personal perspectives (Ahad et al., 2023 ). Its presence is recognized in various regions, including the Middle East (Abdullah & Brown, 2011 ; Dardas & Simmons, 2015 ; Sharaf et al., 2012 ), India (Zieger et al., 2016 ), Europe (Evans-Lacko et al., 2012 ), the United States (Drapalski et al., 2013 ; West et al., 2011 ), and other parts of the world (Adewuya et al., 2011 ; Chien et al., 2014 ).

Furthermore, a scoping review of 61 studies concluded that internalized stigma in PWMI was common, leading to depression and a poor quality of life, while a meta-analysis of 52 studies, with a total sample size of 11,072, confirmed these findings (Del Rosal et al., 2021 ). Persons with mental illness experience rejection, isolation, and discrimination in employment, education, and housing because of the prejudiced stance of the general public (Mohammadzadeh et al., 2020 ; Zolezzi et al., 2018 ). Families of PWMI also share the negative impact of mental illness stigma, significantly affecting family functioning (Al-Hadi Hasan & Musleh, 2017 ; Shi et al., 2019 ; Van Der Sanden et al., 2016 ) and increasing the burden of care (Hoseinzadeh et al., 2022 ). They internalize the public’s prejudice towards mental illness and, as a result, suffer from the negative consequences of stigma (Al-Hadi Hasan & Musleh, 2017 ; Shi et al., 2019 ; Van Der Sanden et al., 2016 ).

The stigma experienced by families of PWMI is estimated to affect nearly 80% of PWMI (Mohammadzadeh et al., 2020 ) This stigma has been labelled courtesy stigma or stigma by association (Van Der Sanden et al., 2016 ), and affiliate stigma (Chang et al., 2017 ; Shi et al., 2019 ; Zhang et al., 2018 ). Courtesy or stigma by association refers to the perceptions of family members regarding the public’s negative attitudes towards mental illness (Van Der Sanden et al., 2016 ). In contrast, affiliate stigma refers to the internalization of public prejudice by family members of stigmatized individuals, which they then direct towards themselves (Shi et al., 2019 ). Affiliate stigma as well has been reported to negatively influence the health of PWMI and decrease their quality of life (Ong et al., 2016 ). Perceptions of stigma among family members can create delays in help-seeking for mental illness by PWMI (Fernando et al., 2017 ). Consequently, mental illness has been regarded as a “family illness” because of its profound influence on the entire family (Yin et al., 2020 ).

While stigma towards mental illness is a global issue, it may be increasingly challenging in collective societies, such as those in the Middle East, where the individual’s identity is inseparable from that of the wider social context (Kehyayan et al., 2020 ). In Arab, Middle Eastern countries, particularly in the Gulf region, family and social relations are central to personal success, well-being, and quality of life (Abdul-Haq, 2008 ; Al-Ghanim, 2012 ). In these societies, where family reputation is highly valued, maintaining secrecy about a family member’s mental illness becomes paramount, adding further stress to the already challenging circumstances of supporting a relative with such a condition (Kehyayan et al., 2020 ).

Compared to Western countries, Arab cultures hold distinct values and beliefs regarding mental illness (Dardas & Simmons, 2015 ; Zolezzi et al., 2018 ), often attributing it to divine punishment, evil spirits, or evil eye (Ciftci, 2013 ; Ghuloum et al., 2010 ). Such perspectives can imply that a diagnosis of mental health issues is indicative of moral failings, which may be attributed to poor literacy about mental illness (Elyamani et al., 2021 ). As family members may be the first to notice signs of mental illness or to learn of a diagnosis, their internalized stigma, similar to that experienced by PWMI, may delay supportive action for the PWMI to seek timely treatment (Dockery et al., 2015 ). Therefore, it is prudent that researchers and care providers understand internalized stigma towards mental illness from the perspective of families. While several studies about the experience of PWMI with stigma, or the general public’s perceptions and attitudes toward mental illness have been published in Arab countries (Al-Hadi Hasan & Musleh, 2017 ; Ciftci, 2013 ; Dalky, 2012 ; Dardas & Simmons, 2015 ; Kehyayan et al., 2021 ; Zolezzi et al., 2018 ), to the best of these authors’ knowledge, no studies have examined stigma from the families’ perspectives in Qatar, a country characterized by its Arab and Muslim identity.

This study is part of a larger project examining the experience of stigma from the perspective of PWMI (Kehyayan et al., 2021 ; Stirling et al., 2019 ), their families, and the healthcare professionals caring for them (Zisman-Ilani et al., 2013 ). In this paper, we aim to describe our findings on the level of internalized stigma among family members in Qatar and examine the relationships between stigma scores and sociodemographic data.

Methodology

Design, setting and study population.

This cross-sectional quantitative study was carried out at the Mental Health Service (MHS) of the Hamad Medical Corporation, the principal provider of secondary and tertiary healthcare in the State of Qatar. The MHS is the main provider of specialized mental health care and treatment in Qatar (Hamad Medical Corporation, 2018 ), offering both inpatient and outpatient services.

With the help of clinical staff, who were informed about the study, the research team recruited 417 patients from May to October 2018 who visited the MHS for their outpatient appointments. Internalized stigma among these patients was described by the researchers in a published paper (Kehyayan et al., 2021 ). These patients identified a “family member” who had accompanied them for their appointments. With the consent of the patients, their identified family members were invited to participate in the study.

The inclusion criteria for family members were (1) having accompanied the PWMI; (2) being identified as “family” by the PWMI; (3) speaking one of the most common languages in Qatar (Arabic, English, or Urdu); and (4) providing signed informed consent to participate in the study. Family members who did not meet any of the above inclusion criteria were excluded from the study.

Study sample and sample size calculation

Participants in this study were recruited through a convenience sampling procedure. To estimate the mean stigma scale score within a margin of error of 0.15 standard deviation (SD) units using a 95% confidence interval, a sample size of 200 family members was calculated. This calculation ensures that the estimated mean stigma score is precise and reliable, accounting for variability within the population.

Measurements

Socio-demographic data.

A questionnaire was developed by the researchers to collect sociodemographic data such as age, gender, ethnicity, employment, religious affiliation, and education level.

Family Members’ Internalized Stigma of Mental Illness (FISMI) scale

The 12-item FISMI scale was adapted from the “Parents’ Internalized Stigma of Serious Mental Illness Scale” (PISMI) (Zisman-Ilani et al., 2013 ). The PISMI was adapted from the original 29-item “Internalized Stigma Mental Illness (ISMI)” developed by Boyd Ritsher et al., 2003 (Boyd Ritsher et al., 2003 ). Its adaptation involved modifying the language to make the items relevant to parents. For example, the item “I am embarrassed or ashamed that I have a mental illness” in the original ISMI was modified to read “I am embarrassed or ashamed that I have a son or daughter with mental illness”. The psychometric properties of the English and Arabic versions of the PISMI were established by Zisman-Ilani and colleagues (Zisman-Ilani et al., 2013 ). The PISMI is moderately reliable (α = 0.76).

In this present study, we made further adaptations to the PISMI scale (with permission from the authors) by modifying the language to be suitable for non-parental family members, as identified by the PWMI. We renamed the scale “ Family Member’s Internalized Stigma of Serious Mental Illness (FISMI) Scale” . For example, the item “I am embarrassed or ashamed that I have a son or daughter with mental illness” in the PISMI was modified into “I am embarrassed or ashamed that I have a family member with mental illness”. Based on the relationship of the patient to the family member, the research assistant (RA) who interviewed family members used the appropriate term (e.g., son, daughter, father, mother, sister, etc.).

The FISMI scale uses a 4-point Likert-type scale to measure responses (1-strongly disagree, 2-disagree, 3-agree, 4-strongly agree) to each statement with higher scores indicating high stigma (Boyd Ritsher et al., 2003 ). The mean stigma score per participant was calculated by taking an average of all responses to the 12 FISMI statements for that participant. Scores 1.00 to 2.00 are interpreted as “minimal to no internalized stigma”, 2.01to 2.50 as “mild internalized stigma”, 2.51 to 3.00 as “moderate internalized stigma”, and 3.01 to 4.00 as “severe internalized stigma” (Boyd Ritsher et al., 2003 ). Scores above 2.5 are considered high levels of stigma (Lysaker et al., 2006 ).

FISMI sub-scales

The FISMI is comprised four subscales to assess various dimensions of self-stigma related to mental illness. These dimensions include: alienation which captures the sense of being devalued or marginalized as a result of being a part of society; stereotype endorsement , which measures the level of agreement with negative stereotypes associated with mental illness; discrimination experience , which assesses the extent to which individuals perceive mistreatment or unfair treatment from others due to biases related to mental illness; and social withdrawal , which reflects the tendency to avoid social interactions with others because of one’s mental illness.

Cultural considerations in adapting FISMI

To ensure the cultural suitability for Qatar, the FISMI was translated into Arabic by two faculty who were proficient in the Arabic language. It was also translated into Urdu by two other faculty who were proficient in both English and Urdu. All translations were subjected to established forward-backward translation methods (Toma et al., 2017 ). The FISMI was validated for the context of Qatar by administering the questionnaire to a sample of 15 participants (5 in English, 6 in Arabic, and 4 in Urdu). No changes were deemed necessary. These data were not included in the analysis.

Data collection

Data collection took place from May to October 2018. The Research Assistants (RAs), who were proficient in two of the three languages of the questionnaire and had been trained by the primary investigator (VK), screened family members according to the pre-defined inclusion/exclusion criteria and obtained informed signed consent prior to participation. The RAs then interviewed each family using the FISMI questionnaire. Every “family member” participant was assigned a unique study identifier, ensuring all data were securely stored. Participants were informed that they could withdraw their consent at any time, yet no withdrawals were requested.

Ethical considerations

Ethical approval was obtained from the Institution Review Boards of Hamad Medical Corporation (16231/16), Weill Cornell Medicine-Qatar (IRB#16-0016), and the University of Calgary in Alberta, Canada (REB160878). Written informed consents were collected from all participants in the study.

Statistical analysis

Socio-demographic data were summarized using descriptive statistics. Overall, the mean stigma score per participant was calculated by taking an average of all responses to the 12 FISMI statements for that participant. The FISMI subscale scores were also summarized for the sample. The score for each sub-scale was calculated by taking the mean of the responses to the items in that sub-scale. For both sub-scale and overall scores, scores above 2.5 were considered high levels of stigma (Lysaker et al., 2006 ). The FISMI data were summarized for prevalence and level of stigma.

Descriptive and analytical statistics were conducted using IBM-SPSS version 24 (IBM Corp., 2016). Bivariate and multivariate analyses were performed to explore associations between demographic variables and stigma scores. Logistic regression analysis was conducted to examine the association between demographic variables and high stigma score (> 2.5). Variables with a p -value of less than or equal to 0.20 at the bivariate level were used to build the final multiple regression model. Variables that were not significant or did not have a confounding effect on other variables were excluded from the final model. For the logistic regression analysis some of the variables were recategorized to decrease the number of degrees of freedom given the small sample size. A significance level of 5% was set for this study.

Sociodemographic characteristics

A total of 106 participants completed the interview. Almost half of them (47%; n  = 49) were between the ages of 40 and 60 years. There were almost equal representations of males (49.1%; n  = 52) and females (50.9%; n  = 54). Most participants were first-degree family members of the participating PWMI. A third of the participants (30.2%; n  = 30) reported being parents of PWMI and a similar number reported being an offspring or a sibling of PWMI (28.2%; n  = 33), while only about 8.5% reported being a relative or friend. Most participants (93.8%) were married, and about one third of those were married to the accompanied PWMI. Two thirds of the respondents (approximately 66.3%; n  = 69) were working professionals with at least a college degree (65.1%; n  = 69) and had an income above 10,000 QAR (US $2700) per month 60.5% ( n  = 64). About half of the participants were South Asian (48.1%) and 40% were Arab. Sociodemographic data are summarized in Table  1 .

Levels of internalized stigma

The mean stigma score was 2.04, with a standard deviation (SD) of 0.42, and scores ranged from 1.00 to 3.42. Nearly 23% of the participants strongly agreed with the items on the scale.

The mean FISMI scores are presented in Table  1 . The mean stigma score for family members who were married was significantly higher than that for those who were not married (2.09 vs. 1.78, p  = 0.002). There was a significant difference in the mean FISMI scores between different ethnicities ( p  < 0.001). Participants of South Asian (M = 2.18; SD = 0.42) and African (M = 2.08; SD = 0.12) ethnicities reported higher stigma scores than other ethnicities.

Table  2 shows the overall mean FISMI score and the mean score for each of the sub-scales. The internal consistency reliability of the FISMI scale as measured by Cronbach’s alpha was good (Cronbach alpha = 0.87). The overall mean stigma score on the FISMI was 2.04 (SD = 0.42), which is considered “mild internalized stigma”.

Table  3 shows the results of bivariate analysis. We used mean stigma over 2.5 as the outcome variable. The bivariate analysis showed that the 40-60-year-old age group had a significantly higher likelihood of having high stigma (OR 3.73, 95% CI: 1.20–11.50, p  = 0.022) compared to those 30 years or younger. Those who were married were 6.75 times more likely to report high stigma scores (OR 6.75, 95% CI: 2.08–21.96, p  = 0.002). In contrast, participants with at least some college education (OR 0.38, 95% CI 0.15–0.97, p  = 0.042), offspring of PWMI (OR 0.29, 95% CI: 0.09-0.97, p  = 0.044), and siblings of PWMI (OR 0.23, 95% CI: 0.06–0.84, p  = 0.026) were less likely to report high stigma.

Table  4 shows the results of multiple linear regression analysis for FISMI scores. After adjusting for all variables in the model, there was a significant association between the overall mean stigma score and marital status, education level, and ethnicity. Being married was found to be a predictor of higher levels of stigma (β = 0.26; p  = 0.017), while having a college or higher education predicted lower levels of stigma (β= -0.65; p  = 0.016). Ethnicity was also found to be associated with overall mean stigma score, with non-European ethnicities reporting a higher level of stigma.

In multivariate logistic regression analysis, as shown in Table  5 , those with at least some college degree had significantly lower odds of exhibiting high stigma (AOR = 0.254, p  = 0.023) and those who were married had significantly higher odds of exhibiting high stigma (AOR = 7.909, p  = 0.034).

The aim of this study was to examine the internalized stigma in families of PWMI and to explore any relationships between stigma scores and sociodemographic data. This is the first known study to examine stigma from the perspectives of family members of PWMI in Qatar. As the experience of stigma varies among cultures, it was necessary to study this phenomenon in Qatar. While Qatar’s mental health strategy highlights the issue of stigma related to mental illness, a surprising finding of this study was that the stigma levels reported by family members were mild. Interestingly in a study by these same researchers on internalized stigma in the PWMI who had accompanied the family members had also shown a similar mild scores (Kehyayan et al., 2021 ). In contrast, however, in the qualitative arm of that same study, Stirling et al. (Stirling et al., 2019 ) reported that PWMI acknowledged the stigmatizing experience they had had and their fear of disclosing their mental illness to members in their social networks. The mild stigma levels reported in families could be attributed to their close relationships with the PWMI, leading to increased acceptance and reduced internalized stigma. About 92% of the families in this study were within the same family unit as either spouse (30.2%), parent (30.2%), offspring (17.0%), or sibling (14.2%). Thus, the mild internalized stigma score in the families may be reflective of their feelings of “shame, blame, and contamination” as reported by Larson and Corrigan (Larson & Corrigan, 2008 ). Stigma scores might be reported as lower by biological family members, possibly due to their protective and accepting attitudes towards loved ones with mental illness. This observation aligns with previous literature on the experience of mental illness stigma in other Arab countries (Dalky, 2012 ). Our participants experienced social withdrawal more severely (mean score 2.41; see Table  2 ) compared to the components of stereotyping (mean score 2.10) and discrimination (mean score 1.86) (Dalky, 2012 ). Social withdrawal could be a strategy to shield families of PWMI from stereotyping and discrimination, rooted in prevalent misconceptions about mental illness. However, this withdrawal can also lead to isolation, hinder access to care, and diminish quality of life by limiting meaningful participation in social or professional activities for PWMI and family members (Zolezzi et al., 2018 ). Conversely, social inclusion is associated with mental health recovery, increased social participation, and greater acceptance of PWMI (Tew et al., 2012 ). Understanding social withdrawal in depth is crucial for identifying the needs of PWMI and their families and fostering social acceptance.

Culture cannot be separated from the experience of stigma. Goffman ( 1986 ) (Goffman, 1986 ) described it as a phenomenon that exists in the relationship between the quality being assessed (e.g., having a mental illness) against the broader context (society where mental illness is viewed as reflecting on morality or trustworthiness) (Goffman, 1986 ). Similarly, in discussing the results of this study, it is important to consider the social environment within which it was conducted. Qatar, an Arab and Islamic nation, considers the family to be the main pillar of society (General Secretariat for Development and Planning, n.d.). As a Muslim-majority country, Qatar exhibits high levels of religious adherence and collectivist views, akin to other Arab nations (General Secretariat for Development and Planning; Cochrane et al., 2024 ). Although few studies have focused on stigma within Arab cultures, previous research has shown that the level of stigma towards mental illness increases with higher religiosity (Al-Natour et al., 2021 ). Moreover, Arab culture is characterized by collectivism, which has been correlated with higher levels of stigma toward mental illness compared to individualist cultures (Papadopoulos et al., 2013 ).

Married status was found to predict a higher level of stigma in our sample. This is supported by literature from other countries, as well as some evidence that unmarried status is a predictor of lower stigma levels (Zolezzi et al., 2018 ). While being married to a PWMI may add strain to the relationship and feelings of stigma, having a close family member with mental illness may also add strain on the marriage. In Qatar and Arab cultures at large, marital strain may negatively influence the extended family as many married couples live in large extended family households, and marriage is often seen as a joining of two families, not just individuals. In turn, marital strain resulting from mental illness stigma may further isolate PWMI and their families, reduce opportunities for social inclusion of PWMI and increase misunderstanding of the illness. Available literature exploring the effects of mental illness stigma on marriage, from the perspective of family members of PWMI, is limited. However, a study revealed that married persons are more likely to seek professional help for mental illness, possibly driven by an effort to alleviate marital problems (Al-Krenawi, 2005 ). Therefore, married family members (81.1%; Table  1 ) in our study may also be supporting the PWMI to alleviate their own marital strain, explaining the higher level of stigma measured. As family members, especially of the first degree, are essential players in the recovery journey of PWMI, their mental well-being is equally important to care providers and decision makers. Social support is a critical component of recovery in mental illness (Corrigan, 2006 ), and as our data showed that most family members participating in the study spent more than 40 h per week with the PWMI, understanding the challenges and benefits of lengthy exposure to a PWMI can inform provision of family-centered mental health care.

Ethnicity has been shown to be strongly associated with stigma scores in families of PWMI, with non-European ethnicities showing higher stigma scores more frequently than European ethnicities, most notably among South Asians. In South Asian countries, studies have also shown high levels of stigma and discrimination associated with mental illness (Ogbo et al., 2018 ). In the Middle East, studies have found that Arab families from the United Arab Emirates are reluctant to seek help from healthcare professionals for children with mental illness due to fear of stigmatization (Eapen & Ghubash, 2004 ), while those in other Arab countries believed that PWMI were of poor character, faith, and/or morals (Zolezzi et al., 2018 ). Therefore, further research is critical to understanding mental illness stigma with a socio-cultural lens to uncover its roots, impact, and potential treatments.

Higher education (college and above) levels predicted lower stigma scores in our sample. About 74% of our sample had some college or higher education. This finding suggests that those who are better educated may be at an advantage in accessing and understanding information related to mental illness, thereby gaining better insight when interacting with a PWMI. Similar findings are discussed in the literature (Zolezzi et al., 2018 ). While approximately one third of Qatar’s residents (citizens and expatriates) have university education or higher, there is still a significant portion, between 17 and 25% of the population that has less than primary level of education (Ministry of Development Planning and Statistics, 2017 ). Considering the higher level of stigma found in the less educated group in our sample, it is prudent that care providers and public health programs take this attribute into consideration when planning mental health promotion activities.

Implications to practice

While the Middle East region represents a significant percentage of the world population, there are few published works on mental health from this area. The findings of this study shed much-needed light on internalized stigma in families of PWMI in Qatar. Although previous studies have correlated religion, collectivism, and Arab culture with higher levels of stigma toward mental illness, our study did not find these as significant factors, suggesting that more research is needed to understand the impact of culture on stigma. Nevertheless, it is crucial to involve cultural brokers, leaders, and practitioners in supporting PWMI and their families.

Some suggestions in the literature for healthcare professionals include providing social and compassionate support (Akbari & Mousavikhatir, 2012 ) and teaching PWMI coping strategies (Nxumalo & Mchunu, 2017 ). A family-centered model of practice, which includes families in treatment planning, is recommended due to their central role in caring for their family members (Dardas & Simmons, 2015 ; McNeil, 2013 ; Park & Park, 2014 ). Another key role for healthcare professionals is the early detection and intervention of caregiver strain in families, ensuring that this critical support system for PWMI is not eroded. Finally, a stigma community-level intervention, in collaboration with healthcare professionals, may help improve mental health literacy, change misconceptions about mental illness, and result in a more open and accepting societies. While this study had a small sample size, it unveiled important factors that contribute to internalized stigma in families of PWMI. These findings may guide further research to better understand and address mental illness stigma.

Strengths and limitations

The strengths of this study included consistent data collection procedures, the use of standardized and psychometrically validated instruments (FISMI), an ethnically and economically diverse sample and minimal missing data through in-person interviews conducted by research assistants.

Several limitations were identified in this study. First, the cross-sectional nature of the study prevents the drawing of causality conclusions. Second, the convenience sampling method might affect the representativeness of the sample. However, we consider our sample to be somewhat representative of Qatar’s population with Qataris comprising 8.5% of our sample compared to 11.6% of the larger population, and Muslims making up 79.2% of our sample compared to 65.0% in the population (Pew Research Center, 2019 ). Moreover, the study might have encountered voluntary participation bias due to the convenience sampling method, as participants who chose to engage may possess lower levels of stigma and thus be more willing to discuss stigma and mental health issues. Third, the sample size calculated was unattainable during the study period, limiting the interpretation of regression analysis. The recruitment strategy, requested by the ethics boards as a condition for approval, required obtaining patient permission prior to recruiting family members, which may have contributed to the challenge in achieving the target sample size. Fourth, collecting data through face-to-face interviews might have introduced response bias, as this method could lead participants to provide fewer stigmatizing responses, possibly not fully reflecting the extent of stigma they have experienced or are experiencing.

Finally, since recruitment was conducted at a single outpatient clinic in Qatar, the study does not capture stigma data from individuals facing acute mental health challenges in inpatient settings, those avoiding mental health care due to stigma fears, or those receiving treatment in private clinics or primary health care centers.

This study represents the first effort in Qatar to explore the nature of internalized stigma related to mental illness in family members of PWMI. It sheds light on the presence of internalized stigma in family members. Despite the overall stigma scores not being high, specific sociodemographic factors were found to influence stigma trends within our sample. Although the interpretation of these findings is constrained by the limitations of the study, they suggest the need for further research into mental health stigma among PWMI’s families. Such research should engage healthcare providers and academics, considering the impacts of culture, marital status, and education levels. Future investigations in this field are crucial to deepen our understanding of internalized stigma among this population and to guide efforts aimed at reducing stigma.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on request.

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Acknowledgements

The authors would like to thank the following for their role in this study: Mental Health Service, Hamad Medical Corporation where data collection took place, and for supporting this study. We also thank study participants for participating in the study; SB and KH for interviewing participants. Dr. Jennifer Boyd for permitting the use of ISMI (Internalized Stigma of Mental Illness), and Dr. Y. Zisman-Ilani for the adaptation of PISMI (Parents’ Internalized Stigma of Mental Illness). We would like to thank Qatar National Library for funding the publication of this article.

Open Access funding provided by the Qatar National Library. This study was made possible by NPRP 9-270-3-050 grant from the Qatar National Research Fund (a member of Qatar Foundation). The statements made herein are solely the responsibility of the authors.

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University of Calgary in Qatar, P.O. Box 23133, Doha, Qatar

Mental Health Services Hamad Medical Corporation, Doha, Qatar

Suhaila Ghuloum

Primary Health Care Corporation, Doha, Qatar

Tamara Marji

Weill Cornell Medicine – Qatar Education City, Doha, Qatar

Hassen Al-Amin & Ziyad Mahfoud

Clinical Effectiveness Department, Primary Health Care Corporation, Doha, Qatar

Muna Abed Alah

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VK was the principal investigator of this study; he was involved in conceptualizing and designing the study, data collection, data analysis, drafting and critically reviewing the manuscript. SG, ZM and HA were also involved in designing the study and critically reviewing the manuscript. HO initiated drafting the paper. ZM was involved in the statistical analysis and writing up the statistical analysis and results sections of the manuscript. TM was the lead in data collection, data entry and ensuring data quality, and preparing the data presentation in the manuscript. MA was involved in critically reviewing and editing the manuscript and submitting it. All authors read and approved the final manuscript.

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Correspondence to Muna Abed Alah .

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Kehyayan, V., Omar, H., Ghuloum, S. et al. Internalized stigma and its correlates in families of persons with mental illness in Qatar: a cross-sectional study. Curr Psychol (2024). https://doi.org/10.1007/s12144-024-06686-y

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Level of institutional delivery service utilization and associated factors among women who gave birth in the past 12 months, Ga’an libah district, Marodijeh region, Somaliland: a community-based cross-sectional study

• Mustakim Mohamed 1 ,
• Barkhad Aden Abdeeq 2 ,
• Ahmed Ismail Mohamed 3 ,
• Hassan Abdi Jama 4 ,
• Fikru Tafese 5 &
• Muluneh Getachew 5  

BMC Health Services Research volume  24 , Article number:  1085 ( 2024 ) Cite this article

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Institutional delivery has been considered one of the important strategies to improve maternal and child health and significantly reduce birth-related complications. However, it is still low in developing countries though there are some improvements. even among the community who has access to the health institutions weather health center and hospital including Somaliland. Hence, the aim of this study was to assess the level of institutional delivery service utilization and associated factors among women who gave birth in the last 12 months in Ga’an libah district, Marodijeh region, Somaliland.

The community-based cross-sectional study was conducted among women who gave birth in the last 12 months from September to December 2022. A simple random sampling technique was employed to select study participants from a total of sample population. Data was collected using semi-structural administered questionnaire through interviewing women. Data was collected with online mobile data collection (Kobo collect). SPSS version 25.0 was used for data management, entering and analysis. Bivariate and multivariable logistic regression models were fitted to determine the presence of a statistically significant association between independent variables and the outcome variable with p -value < 0.05.

Level of Institutional delivery services utilization in Ga’an libah district was 53.9% [95% Cl 48.2–59.6] gave birth at health institutions. Women who can read and write local were (AOR 2.18, 95% CI 1.08–4.56, p <0.01), Women with their husband can be capable to read and write are [(AOR = 6.95, 95% Cl 2.82–21.58, p <0.002]). Additionally, ability to cost transportation for referral [AOR 5.21, 95% Cl 2.44–11.13, p <0.001]. not good services available [AOR 0.07, 95%Cl 0.01–0.10, p <0.02]. lack of maternal health and child knowledge [AOR 0.034, 95% Cl 0.02–0.57, p <0.01]. were observed associated with level of institutional deliver services utilization.

The institutional delivery service utilization was relatively high compared to national demographic health services in the study area. A large proportion of women gave both at home without a skilled attendant. Therefore, this finding has important policy implications since changes in the cost of the health service and perceived quality would mean changes in client satisfaction as well as their choice, as well emphasize to expectant women can receive medical advice and ambulance for referrals.

Peer Review reports

Institutional delivery is a delivery that takes place at any medical facility with a skilled delivery assistance [ 1 ]. Utilizing institutional delivery services is one of the major and proven strategies to promote maternal health and well-being and minimize maternal mortality by ensuring safe delivery and lowering issues related to and occurring during birth, Worldwide, around 81% of urban and 61% of rural women gave birth in a medical facility. Worldwide, the major causes of maternal mortality are hemorrhages (24%), infection (15%), Unsafe abortion (13%), prolonged labor (12%) and eclampsia (12%), where primary causes of maternal mortality in Africa are hemorrhage (34%), other direct causes (17%), infection (10%), hypertensive disorders (9%) and obstructed labor (4%), abortion (4%) and anemia (4%) [ 2 ].

Globally, 75% of neonatal deaths occur in the first week of life, with over 1 million babies dying within the first 24 h in 2019. Preterm birth, childbirth-related complications (birth asphyxia or lack of breathing at birth), infections, and birth abnormalities accounted for the majority of newborn deaths in 2019 [ 3 , 4 ].

World Health Organization reported that the mortality rate for children under five in Sub-Saharan Africa remained the highest in the world, with 74 (68–86) deaths per 1000 live births, which is 14 times greater than the risk for children in Europe and North America [ 5 ]. Despite global progress in lowering maternal death, there is an urgent need for immediate action to accomplish the ambitious 2030 sustainable development goals (SDGs) and eventually eliminate preventable maternal mortality [ 6 ]. In 2020, According to the same research, the top causes of death for children under five continue to be infectious diseases such pneumonia, diarrhea, and malaria as well as problems related to preterm delivery, birth asphyxia, trauma, and congenital abnormalities [ 7 ].

In Sub-Saharan countries, 75% of urban and 40% of rural women gave birth in health facilities. [ 8 ]. Access to health care has four dimensions; geographic (or Physical), accessibility, availability, affordability (or financial access), and acceptability (cultural access). Geographic accessibility is concerned with the relationship between the location of health care facilities (supply factor) and the location of those who needs these services and their transportation opportunities (demand factors). Availability includes issue such as the level of supply of staff or drugs, the degree of fit between the hours of services of health care facilities (opening hours) and the times that individuals need services to be provided. Affordability is concerned with the with the degree of fit between the full costs to the individuals using the services and the individual’s ability to pay in the context of the household budget and other demands on that budget. Acceptability is concerned with the fit between provider and patient attitudes towards and expectations of each other [ 9 , 10 ].

Pregnancy and childbirth complications that may lead to healthcare mortality and morbidity are usually avoided by adopting skilled antenatal care (ANC), delivery care, and postnatal care [ 11 ]. Skilled delivery at a health facility or institution can significantly minimize maternal and newborn deaths due to birthing difficulties and infections because it assures full medical care and aseptic settings [ 12 ].

Ethiopia Oromia region 18.2% [ 13 ]. Increasing the proportion of births carried out at a health facility and under the supervision of health professionals is crucial for reducing health risks for women and children.

Maternal deaths involve both direct and indirect causes. Approximately 80% of maternal deaths result from causes directly related to pregnancy and childbirth [ 14 ]. In Somalia, a substantial proportion of births take place at home. And only a few skilled health providers attend deliveries. The proportion of births attended by a skilled health professional and delivered in a health facility has stayed at approximately 21% [ 15 ]. In other African countries, like Cameroon, 68.7% of women deliver in health facilities [ 13 ].

According to the 2019 Ethiopian Demographic health survey (EDHS) shown, the residence, 72% of urban births were assisted by a skilled provider, compared with 43% of births in rural areas. Similarly, 70% of urban births were delivered in a health facility, compared with 40% in rural areas. Somali Region has the lowest percentage of births delivered by a skilled provider or delivered in a health facility (26% and 23%, respectively), while Addis Ababa has the highest percentages for both indicators (96% and 95%, respectively). The percentage for both indicators increase along with the women’s education. For example, 35% of births to women with no education were assisted by a skilled provider and 33% were delivered in a health facility. Among women with more than secondary education, 93% of births were assisted by a skilled provider and 93% were delivered in a health facility [ 16 ].

Institutional delivery services in Ethiopia are extensively poor utilized. Maternal awareness of labor danger signs, frequent ANC visits, a highly educated husband, and household affluence predicted service utilization. As a result, adequate attention must be made to upgrading education, education, expanding health institutions, and providing awareness on the benefits of antenatal care monitoring and danger signs to ensure that all pregnancies are delivered at health institutions [ 17 ].

According to Somaliland Health & Demographic Survey 2020 (SLHDS), 79% of births were delivered at home, with only about one in every five births (21% in the five years prior to the study) being born in a health facility. Deliveries sponsored by private sector health institutions at 17%, similarly to SLHDS revealed that a slightly more than two third (67%) of births was delivered at home. Only one third (33%) of births in the five years preceding the survey was delivered in a health facility. In public facilities, deliveries are more common in rural settlements which is a 24% compared to the private sector-supported facilities are 9%. More than one third (39%) of deliveries occur in public facilities in urban settlements, compared to 20% in private facilities [ 18 ]. this study is aimed to assess the level of institutional delivery service utilization and associated factors among women who gave birth in the past 12 months prior to the study at Ga’an libah district, Marodijeh region, Hargeisa, Somaliland.

Methods and material

Study area and period.

The study was conducted from September 30th to December 31st, 2022, in Hargeisa, Somaliland’s capital city. Somaliland is an unrecognized self-declared sovereign state that isn’t recognized internationally. Somaliland has country borders with Djibouti, Ethiopia, the Gulf of Aden and Somalia in the northwest, south and west, north and east respectively. The capital city of Somaliland is Hargeisa, with an estimated population of 1.3 million individuals. Hargeisa had encompassed eight major district under its local municipal administration. Hargeisa has a latitude and longitude of 9°0.5624” and 44°.177”, correspondingly, and is 1,334 m (4,377 feet) above sea level, in addition to this, women with reproductive age across the region were estimated 6,285 individuals were status on never married, married, widowed and divorced, conversely, the number of health institution that provides maternal health care services are six maternal health centers and one district hospital under Ga’an Libah district [ 15 , 19 ].

Study design

A community-based cross-sectional study design was used with women who had given birth during the previous year.

Source of population

The population was selected from all reproductive women in the Ga’an libah district who had given birth during the previous 12 months, regardless of the outcome of their pregnancy.

Study population

Womens who live in and are available in the Ga’an libah district, specifically childbearing women who have given birth within the last 12 months, regardless of the outcome of the birth.

Eligibility criteria

Inclusion and exclusion criteria.

All childbearing women who had given birth in the previous 12 months in the district and were available during the study period in Ga’an libah district, regardless of birth outcome. A childbearing woman who had not lived in the study region for the previous six months, women with difficulty hearing, and those who refused to respond were excluded from the study.

Sample size determination & sampling procedure

The study’s sample size was calculated using a single population proportion method based on the following assumptions: (P) 21.0% of proportions of institutional delivery service utilization in the Somaliland Health and Demographic Survey [ 15 ], 95% confidence interval (CI) (1.96), and 5% margin. The ultimate sample size of study participants was 280, including a 10% non-response rate.

Regardless of the result of the birth, the sample consisted of women who gave birth within the last 12 months in the district. A woman who gave birth in the last 12 months in the district, regardless of their birth outcome were in the sample. Sample sizes were distributed proportionately to the number of households within each of the three clusters in the Ga’an libah district. As a basic random sampling technique, the sampling was initiated by choosing an element from the sample frame. The study followed this sample approach after all eligible women who gave birth during the previous 12 months were recorded as a sample frame, women were uploaded to an excel sheet, and a basic random sampling technique was used to determine the sampling unit.

If no response was received after three attempts, the women who was absent or whose home was closed at the time of data collection was counted as a non-respondent. A randomly chosen women was chosen from each randomly chosen home if there were many women living in the same family.

Study variables

Dependent variable.

Institutional delivery service utilization.

Independent variables

Predisposing factors.

Maternal Age.

Partner education.

Women Perception to health providers.

Enabling factor.

Place of residence.

Wealthy index.

Accessible.

Need Factor.

Antenatal care visit.

Delivery service utilization.

Number of ANC visit.

Type of pregnancy (Planned and Unplanned).

Data collection procedure and tools

Data were gathered using a structured questionnaire that was created by analyzing the body of current literature [ 20 , 21 , 22 ]. To maintain the study’s validity and reliability. To test the validity of questionnaire was pretested 5% the total of study subjects. The Sheikh Nour community was performed the pretest which shares the same demographics characteristics as the target location, served as the pretest site for this pilot study. The three main components of the independent variables were need factors, enabling factors, and predisposing factors. Similarly, to check the reliability of the study, Cronbach’s alpha was calculated using coefficient of Cronbach’s alpha with value of 0.674, were considered acceptable. The questionnaire was first written in English, then translated into Somali, the language spoken locally, and then back to English to ensure uniformity. The data was collected by five bachelor’s degree graduate nurses and the researcher were supervised all entire study operations. Those data collectors were recruited from district administration office. One full days of training were provided to the data collectors about the objectives and data collection process by the principal investigator. The data were checked for accuracy and constancy daily by the field supervisors.

Data analysis and quality assurance

Data was entered, cleaned and analyzed Statistical Package for Social Science window (SPSS IBM Version 25.0) by cross checking it’s completeness, the questionnaire was firstly prepared in English and then translated in local language, which is Somali, furthermore, data was pretested by 5% of study participant with a similar characteristics district. The descriptive statistics was used to compute frequencies and percentages for categorical data. Bivariate logistic regression was done to determine the association between dependent and independent variables. The P-value of <0.2 in the bivariate analysis was entered to generate the candidate variables then was perform multivariate logistic regression analysis to control confounders. Multivariate logistic regression analysis was done to perform the determine the relation independent variables to the outcome variable. Variables with a p-value of <0.05 was considered significant associated with the outcome, and adjusted odds ratio (aOR) with a 95% CI.

Operational definitions

Antennal care service utilization.

A women were considered to have used ANC if she were got a check by a health professional (Doctor, Nurse, and Midwife) at least once during her pregnancy [ 23 ]. The variable was categorized into four categories: 1: NO ANC, 2: One ANC visit, 3: Two or three ANC visits, 4: fourth, and more ANC visits.

Maternal marital status

Current marital status of women at the time of the study [ 24 ]. It was categorized into two groups: 0-Not married and 1-Married. Classification of this variable were developed by putting the never married, widowed, divorced, and not living together as currently not married, and putting married and living together as currently married.

Institutional delivery service utilization

Institutional delivery is a delivery that takes place at any medical facility staffed by skilled delivery assistance [ 25 ]. This variable was categorized as 1. Number of women delivered at the health facility 2: number of women delivered at home.

Maternal education

The highest level of education attained [ 26 ]. This were categorized into secondary level was merged because the number of women in the highest education level was very small.

Wealth index

This variable in the data set were recorded into five groups, however, for this study, it was categorized into three groups by assigning the same value as that of the original variable [ 12 ]. it was categorized into three groups by assigning the same value as that of the original variable. The three categories were Poor, Middle and Rich.

Place of residence

Where the women in the study lived at the time of the study. This variable was categorized into two groups and coded as 1 Urban and 2 rural.

Gravidity/ parity

Number of pregnancies reaching viability and not the number of features delivered. This variable was categorized as the number of pregnancies without regarding its outcome [ 27 ]. This variable was categorized 1- One child, 2: Two children 3. Three children 4: fourth and more children.

Utilization

This means the extent to which a given group of people uses services in a specific period [ 28 ]. This variable was measured the number of women who received institutional delivery service utilization or did not receive any medical services at any health facility.

Socio demographic characteristics of study respondents

A total of 280 women was interviewed for the study. The mean age of the study respondents was 30.0 ± 5.68. About 188 (67.1%) of the womens were in the age range of 29–39 years. Similarly, the majority (95.4%) of study respondents were Somalis by ethnicity, 196(70.0%) of both that are unable to read and write the local language, were only 84 (30%) can read and write, in addition, among the respondents, 233 (83.2%) were housewife and husbands also were jobless, whereas 46 (16.4%) was a merchant for small shops/business. Slightly more than half of subjects 144 (51.4%) women were households’ head. Under this study, women under the study nearly half (49.6%) of respondents gave birth to children 4–6 range. Lastly, to assess the income status of study subject’s principal component analysis (PCA) was employed to examine the wealth status by using Twelve variables related to the ownership of selected household assets, the size and the quantity of durable equipment, materials used for housing construction, home ownership, improved water, and sanitation facilities were considered. Ultimately, the generated principal component was divided into three equal quintiles which is Poor, Middle, and Rich categories. More than half 151 (53.9%) of subjects were shown middle income individuals. (See Table  1 ).

Level of institutional delivery services utilization

Overall institutional delivery services utilization among women in Ga’an libah district was 151 [(53.9% with 95% Cl 48.2–59.6)] of them gave birth/utilized at health institutions (hospitals and health facilities). (See Fig.  1 ).

On the other hand, among those womens who did not visit health facilities, the reasons that did not deliver at health facilities during the last pregnancy included lack of privacy, long distance to health facilities, not good service available and sudden onset of labor. (Fig 2 ).

Level of institutional delivery services utilization among Ga’an libah district, Marodijeh region, Somaliland

Reasons respondents are not to utilizing to deliver health institutions

Predisposing and enabling factors

About one-third of respondents 94 (33.6%) their cultural values influence to deliver the health facilities, similarly, more than half of the study subjects (53.6%) proposed to have a challenge with their location geographically not delivering health facilities, in addition, nearly half (48.6%) womens are decision makers for the place of delivery, furthermore, most respondents (84.6%) have proposed that the service at health facilities is costly. (See Table  2 ).

Factors associated with level of institutional delivery service utilization among women at Ga’an Libah district, Marodijeh region, Somaliland

Analysis of bivariate and multivariable logistic regressions was performed under this study, educational status of women and her husbands, antenatal care visit, the ability of cost transportation for referral, what make women not to deliver nearest heath facility, which of the list impedes you not to delivering health facility for your last delivery, these factors found to be significant associated with institutional delivery service utilization. Women who can read and write local language were 2 times more likelihood [(AOR = 2.18, with 95% CI = [1.04–4.56 p-value <0.03]) to give birth in health institutions than women those who can’t read and write.

Conversely, women with their husband can capable to read and write were 6 times [(AOR = 6.94 with 95% CI = [ 2.82–21.58 p-value < 0.003]) more likely to give birth at a health facility compared to those their husband can’t read and write, similarly, womens who capable for cost of transportation of referral were 5 times [(AOR = 5.21 with 95% CI = (2.44–11.13) p -value < 0.001] more likely to deliver at health institutions.

The respondents those who did not deliver to nearest health facility were [ ( AOR = 0.07, with 95% CI = [0.01–0.10] p-value < 0.021) lower likelihood to deliver and utilize at nearest health facility, with 93.0% reduction in odds. Women under the study were 97% [(AOR = 0.034(0.02–0.57) p-value < 0.019] less likely to deliver/utilize at health facilities due to lack of basic health education the impact of home delivery (See Table  3 ).

The current study showed that the proportion of institutional delivery was (53.9 % with 95% Cl 48.2–59.6) in the study area. However less than a half of women gave birth at home ((46.1% with 95% Cl 40.4–51.8)). A similar study conducted in the central Gondar zone revealed 58.17% were proportional to women who gave birth in health facilities. However, the prevalence of institutional delivery rate was 58.17% study conducted in northwest of Ethiopia which is higher utilization than this study [ 29 ]. The other similar study findings are approximately in line with a study done in the Pawi district of Ethiopia, Kenya, and Sub-Saharan Africa where the proportion of women who gave birth in the health facilities was 60.5%, 61%, and 57% respectively [ 30 , 31 , 32 ]. Conversely, the findings of the current study are lower than studies conducted in the following districts, Mana districts, Bench Maji, and Debre Behan in Ethiopia in which the institutional delivery was 86.4%, 78.3%, and 80.2% respectively [ 17 , 30 , 33 ]. This difference could be due to differences in socio-cultural factors, awareness and Knowledge of facility birth, health education, and accessibility of health facilities in relation to socio-demographic characteristics [ 34 ]. This current study’s findings were higher than the Somaliland demographic health survey (SDHS) which was 33.0% of women gave birth at health institutions [ 15 ]. The reason for these differences might be due to the sample size differences because it smaller than Demographic health survey Somaliland, the current study interviewed 280 women with at least one delivery during the past 12 months and then Andersen’s behavioral model of health service utilization was applied for analysis. In the current study the women’s education, the Husband’s education, the women/Family’s lack of basic health education about health facility services, the women’s ability for transportation costs, and Poor medical service in the residence were found to be significant predictors of not choosing to deliver health facilities [ 15 ].

In other similar studies conducted in Ethiopia found that the husband’s educational status was the other factor significantly associated with institutional delivery service utilization, Women whose husbands had at least a primary school education were nearly 4 times more likelihood to utilize institutional delivery services [ 35 ], in contrast, the current study strongly agreed with the findings of other studies conducted in Ethiopia which found that women’ husband education is associated with institutional delivery services utilization. Additionally, this finding was comparable to the results of other studies where women’s husbands who were jobless are more likelihood to deliver at home [ 17 , 36 , 37 ].

The current study found the influence of traveling (distance in kilometer (KM) spent to reach nearby health institutions was another important factor that was identified. Women who had to walk less than 5 km to the nearest health facility were 10 times more likely to deliver health facilities, than women who could travel more than 5 km (KM). Similarly, women that live at less than 5 km away from a health facility were 9.2 more likely to utilize delivery care from health institutions than those women who live at a distance greater than 5 km away from a health facility in Ethiopia [ 38 , 39 ].

barriers of the health service delivery system in Uganda including policy matters, medical staff, transport, distance and referral mechanism, drugs and medical facilities, costs and financing of services, corruption and bribery, culture and attitudes. Additionally, some common barriers women observed in Ethiopia include financial constraints, cultural beliefs, lack of basic health education about the importance of institutional delivery, and logistical challenges such as distance to health facilities and inadequate transportation. In rural areas, these barriers are more pronounced, leading to lower utilization rates compared to urban areas [ 37 , 40 ].

Socioeconomic status plays a critical role in the likelihood of using institutional delivery services. Higher household wealth and better educational levels are strongly associated with increased use of these services. This trend is consistent across various countries, including Ethiopia and India [ 41 ].

The current study also showed that 48.6% of women’s decision power about the place of delivery was the influencing factor for the institutional delivery of women. Furthermore, the majority of respondents (84.6%) have proposed that the services provided by the nearest health facilities were much higher cost than the other health facilities in downtown, Hargeisa. A similar result was observed in a study in Hadya zoone, Holeta town, and Awash Fentale [ 35 , 42 , 43 ]. In most situations, relatives and neighbors who are the main decision maker in the community can be one of the reasons why laboring women stay at home during delivery [ 40 ].

There is a strong positive correlation between antenatal care (ANC) follow-up and institutional delivery service utilization. Women who attend more ANC visits are significantly more likely to give birth in health facilities. This underscores the importance of comprehensive prenatal care in improving maternal health outcomes, but this study did not observe any relation between ANC and institutional delivery services utilizations [ 40 ].

On the contrary, women with their husband can capable to read and write were 6 times [(AOR = 6.94 with 95% CI = [ 2.82–21.58 p-value <0.003]) more likely to give birth at a health facility linked to those their husband can’t read and write, similarly, women who capable for cost of transportation of referral were 5 times [(AOR = 5.21 with 95% CI = (2.44–11.13) p -value <0.001] more likely to deliver at health institutions. This factor emphasized the understanding and reading the local language perhaps probably promote the institutional delivery, on the other hand knowledge have pivotal role for health facilities delivery.

This study also found that 93.0% of women in the stud area were less likelihood to deliver to the nearest health facility, due to poor medical services. The result is inconsistent with studies conducted in the Metekele zone and Arsi zone in west Ethiopia respectively. This might be due to the institutional delivery service utilization being affected most importantly by the satisfaction of women with the medical service given by the nearest health facility and its quality [ 40 , 43 , 44 ].

For low- and middle-income countries (LMIC) were recommended to increase institutional delivery rates, targeted interventions addressing the specific barriers faced by disadvantaged groups are essential. Strategies could include improving access to affordable healthcare, enhancing public awareness about the benefits of institutional deliveries, and ensuring better coverage of antenatal care services, this study is different recommendation which are to improve the situation health education should be given to women and the community to equip them with knowledge on the importance of skilled attendants during childbirth, furthermore, To ameliorate the situation, women and the community should receive health education to enlighten them on the significance of having skilled attendants during labor. The community’s use of obstetric series will be greatly increased, leading to a decrease in maternal deaths, if universal education is made mandatory, at least up to the community education level, women’s economic status is improved, and women are specifically targeted with reproductive health information. To sustain high levels of facility delivery service consumption, more extensive and tailored interventions and strategies are required. All healthcare institutions offering delivery services should have access to qualified healthcare professionals, and they should treat expectant mothers with the utmost courtesy rather than dehumanizing them. Additionally, vital delivery equipment has to be accessible in rural health institutions, preferably for free, or at a price that is affordable for everyone.

The institutional delivery service utilization was relatively high (53.9%) compared to Somaliland Demographic Health Survey in the study area which is 33.0%. A large proportion (46.1%) of women gave birth at home without a skilled birth attendant. This study identified that women’ educational status, Husband’s education, the ability for transportation costs for referral, poor service delivery, and Lack of basic health education were significantly associated with the outcome. This is a small, but relevant step towards a healthy population who can take care of their children and their family and contribute to the development of their community and country at large. As a result, the challenges of closing the gap of health care, by improving women’s educational levels, expanding the number of health care institutions, and raising awareness of visiting and giving birth in health care facilities must all be tackled.

Recommendations

Health education to the community on the importance of conducting their deliveries in health facilities where skilled personnel will attend them should be intensified and made more effective. This was even proposed by most of the participants during the study survey; sensitization will awaken the low knowledge of safe womanhood practices and strengthen the community’s health education awareness in general. According to this study the major inhibiting factor was a lack of basic health education on the importance of institutional delivery and maternal risks associated with home delivery among women of bearing age. To improve the situation health education should be given to women and the community to equip them with knowledge on the importance of skilled attendants during childbirth. Provision of compulsory universal education at least to the community education level, improvement of the economic status of women, and targeting them with reproductive health information will significantly improve the utilization of obstetric series with a resultant reduction in maternal deaths in this community. More comprehensive and customized interventions/strategies are needed to maintain and sustained high levels of utilization of facility delivery services. Qualified health workers should be made available in all health facilities proving delivery services and that health workers should not humiliate clients but instead should exercise maximum politeness in handling pregnant women. Also, essential delivery equipment should be made available in rural health facilities and be made free if possible or affordable to all. The study further recommends more research on identified specific issues related to the choice of place of delivery among women of different age cohorts and geographical settings and finding out possible interventions to overcome such issues.

The authors suggest that the Ministry of Health establish a support group where expectant women can receive medical advice and ambulance for referrals to nearest health hospitals or specialist.

Limitation of the study

The limitations of this study include respective views. Firstly, the cross-sectional nature of the study design impedes the ability to establish a temporal relationship between trigger and outcome. Consequently, causal interpretations and the direction of causation cannot be definitively determined. Furthermore, the study is vulnerable to probable recall bias among participants, particularly when answering questions related to events such as the actual date of delivery history. The accuracy of reported information may be influenced by memory limitations or variations in individual recall.

Data availability

data is avaiable for corresponding author ‘s on reasonable request.

Abbreviations

Antenatal care

Auxiliary nurse midwife

Community-based education

Community-based newborn care program

District public health office

Developmental team training program

Expected date of delivery

Maternal mortality ratio

Ministry of heath

Ministry of national planning

non-governmental organization

Primary health care center

Primary health care – outreach clinic

Skilled birth attendant

Sustainable development goal

Somaliland Demographic and Health survey

Traditional birth attendant

United nation child’s fund

World Health organization

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Acknowledgements

The authors are highly appreciative to Jimma University Department of Health Policy and Management for receiving ethical approval for this study. We would like to extend our acknowledges to the study participants, supervisors, and data collectors for their time and dedication to achieve this study.

This study did not receive any funding.

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Ahmed Ismail Mohamed

Somali Red crescent Society, Hargeisa, Somaliland

Hassan Abdi Jama

Department of Health Policy and Management, Jimma University, Jimma, Ethiopia

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Contributions

Mustakim Mohamed, Muluneh Getachew and Fikru Tafese designed the study, Mustakim Mohamed, Barkhad Abdeeq, Hassan Jama and Ahmed Mohamed participated in the data collection, performed preliminary analysis and interpretation of data, drafted the first paper prepared them to manuscript. Muluneh and Fikru Tafese assisted in the design, approved the proposal with some revisions, participated in data analysis, and revised subsequent drafts of the paper. All authors read and approved the final manuscript.

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was received from the ethics committee or IRB Jimma University Department of health policy and Management with reference number of IHIRB/591/2022. also, Permission letter was obtained from local administration. Before the data collection, the participants were informed about the purpose of the study, their right to refuse participation and discontinue the interview. Written and Verbal consent were obtained from each participant before to interview to confirm willingness for participation. The participants were informed on the information obtained was kept confidential throughout the process of this study. Similarly, any identification information including the name of the participants were not written on the questionnaire due to confidential kept purpose. The informed consent was verbally explained bit by bit to the illiterate participants and requested permission to proceed, if they weren’t happy, had given a rejection option. All illiterate participants gave verbal informed consent. All study subjects, both literate and illiterate, provided informed consent. The illiterate respondents were informed verbally, and their legal guardians signed on their behalf, while the literate respondents signed their consent. This study was conducted ethically according to the IRB-provided criteria since Mohamoud Askar, a member of the IRB Committee, was designated as an ethical compliance checker during the study period and presented all necessary documentation with supporting data. To maintain confidentiality, no identification information, including the names of the participants, was recorded on the questionnaire. Respecting the principles of ethics, the study followed the principles outlined in the Declaration of Helsinki, underscoring our commitment to ethical practices in human research. In addressing the local context, permission was obtained from relevant Somaliland authorities to conduct this study. This underscores our commitment to respecting the autonomy and rights of individuals involved in the study while aligning with ethical committee-approved procedures. The study didn’t involve experimental and human sample study, likewise the study participants were given a consent/permission both verbal and written form for study respondents. The Authors had declared the study are followed the principle of Helsinki declarations and no human sample were involved.

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Mohamed, M., Abdeeq, B.A., Mohamed, A.I. et al. Level of institutional delivery service utilization and associated factors among women who gave birth in the past 12 months, Ga’an libah district, Marodijeh region, Somaliland: a community-based cross-sectional study. BMC Health Serv Res 24 , 1085 (2024). https://doi.org/10.1186/s12913-024-11330-3

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Received : 30 January 2024

Accepted : 18 July 2024

Published : 17 September 2024

DOI : https://doi.org/10.1186/s12913-024-11330-3

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