Health Education Research

Health Education Research Advance Access originally published online on September 25, 2007
Health Education Research 2007 22(6):907-917; doi:10.1093/her/cym045

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Health education in rural settings in Ghana: a methodological approach

Theophilus Kofi Gokah^*

Cardiff University School of Public Health

^* Correspondence to: T. K. Gokah. Email: tgokah{at}yahoo.co.uk

	Abstract

Top Abstract Context The research setting The methods deployed to... Method Research design Results from interviews Discussion Conclusion Funding Conflict of interest statement References

 
Although the search for appropriate methodology in educating and training rural community populations is on going, previous efforts have yielded few results, some of which have not been successful with consequences for scarce resources. This paper, based on field reports from the Population Communication Project in Ghana, demonstrates that community learning theory can offer understanding of appropriate methodology in rural learning, education and training. The report shows steps used in educating people in Wusuta (a rural community) on health and environmental issues in the community using a mix of traditional and modern approaches. The result shows that the community internalized learning activity and were able to relate their learning experiences to existing traditional values and the need for action. The paper thus offers the method as a solution to rural population training and learning methodology.

	Context

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There is no single or individually approved method of training populations. Each method is dependent on training ‘content’ and ‘context’. Although choice of method may vary, the extent to which training programmes and activities have utilized traditional resources such as folk media remains underexplored in Ghana.

This paper reports on methodological approaches used in a study on developing alternative ways of informing and educating rural communities in Ghana on health and environment issues. Although the search for appropriate methodology in educating and training rural community populations is on going, previous efforts have yielded very little results, some of which have not been successful with consequences for scarce resources. The study had two aims: (i) to investigate the appropriateness of training indigenous communities through folk media—poems, dance drama, story telling, rhymes and sayings—on issues around family planning and HIV/AIDS and (b) to determine whether these messages once existed as part of community cultural norms.

This paper acknowledges different conceptualizations of ‘community’, and stands by Behrman's [1] notion of community as social network of two or more members who share common activity. There are also on-going discourses about what community education is. For instance, Smith [2] sees it as ‘a process designed to enrich the lives of individuals and groups by engaging with people living within a geographical area, or sharing a common interest, to develop voluntarily a range of learning, action and reflection opportunities, determined by their personal, social, economic and political needs’. This definition fits the chosen case study, Wusuta.

The choice of rural settings is justified (in academic discourse) by the fact that 63% of Ghana's population live in rural settings where 55% either work in agriculture, forestry or fishing industries [3]. Rural settings in Ghana and elsewhere are thus synonymous with poverty [4] and deprivation [5–7]. This is not to say that urban poverty and deprivation do not pose challenges to populations and resources. The emphasis on rural settings is based on statistics which calls for a revisit of social policies that impact harshly on rural communities. In referring to rural communities, inferences are made from Hulme's [8] notion that health ‘shocks’ can impoverish families and social exclusion, based on gender, age and disability, and keep people living in that social context poor [9, 10].

Some commentators, for example Asante [11], have argued that modern media, particularly radio, have been successful in tackling development problems in health, education and agriculture in Ghana. Contrary to this thinking, Aborampah and Anokwa [12] argue that the media—radio, television, cinema and print—have not brought any significant changes in the life of Ghanaians. Prior to their views, Schramm [13] did agree that television is an appealing vehicle for literacy in health, education and other areas of rural development, but unlike in urban areas not many people in rural Ghana have access to radio, television or print media because of infrastructural problems and access issues [14]. Instead, in rural areas of Ghana, folk media fills literacy and communication gaps created by a lack of modern forms of communication and can play both supplementary and substitution roles. Its choice is, however, dependent on careful selection and utilization based on project objectives.

Like Easterby-Smith [15], the discussions in this paper draw from existing body of knowledge on social learning theory to argue that community practice where members participate in an activity will induce learning. There is a plethora of academic evidence that links education and training to poverty reduction [16–19]. Closely linked to this thinking is Durham's [20] view that people construct realities of the world around them. As readers will soon see, participants in the reported study were capable of constructing and deconstructing the themes, enacted through traditional dance, drama and recitals about poverty reduction, family planning and environmental degradation. Prior knowledge of Bohla's text that mitigating the social conditions of people through participatory approaches creates incremental gains in socio-economic life, a view earlier expressed by van den Hove [21] and Puertas and Schlesser [22], influenced the choice of methodology (a process later explored in the paper).

	The research setting

Top Abstract Context The research setting The methods deployed to... Method Research design Results from interviews Discussion Conclusion Funding Conflict of interest statement References

 
The pilot research communities were Wusuta and Postin in the Volta and central regions of Ghana, but for reasons of time and space, reporting is limited to Wusuta. Wusuta is famous for its traditional dance groups, the Dumas Borborbor dance group and Akpene dance group. There is little information on the origins of Borborbor. However, an Internet account [23] claims that Borborbor is the most popular social music and dance of the central and northern Ewes of Ghana and Togo. This music and dance, also known as Agbeyeye [New Life] or Akpese [Music of Joy], emerged from a village called Kpando in the Volta Region of Ghana during the independence struggle between 1947 and 1957. Borborbor is derived from an older circular dance called Konkoma. Although this music was initially confined to a few towns and villages in central and northern Eweland, it has now spread to all Ewe-speaking territories in Ghana and Togo.

The Wusuta Borborbor group was noted for its role in political campaign activities of the Convention People's Party, Ghana's first post-independence ruling party, together with others like Konyako brass band in the central region of Ghana serving as a rallying force for the ruling party; apart from being a popular traditional dance among populations in northern Volta, it is an artistic movement for praise and criticism of social, economic and political issues. No doubt it featured prominently in national politics during the first and second republic.

Wusuta has a population of about a thousand people. It occupies the middle portion of the Kpando district bounded to the West by the Volta Lake with a low-lying area to the East. The town is located at the foot of the Kpando Mountain ranges rising 1500 feet in height with forest reserves lining the foot of the mountain ranges. The main source of water is the Dayi River that takes its source from the eastern lowlands. Generally, economic activity is subsistence farming. The subsistence nature of the community means that standard of living is low. Despite its low economic activity (a concern expressed in community education video), social activities like drumming and dancing are major forms of entertainment. These art forms also serve as medium for communicating social, economic and political messages to its people [24, 25].

	The methods deployed to understand the role of traditional media in rural community learning

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The methodological framework in the study is qualitative [26]. In other words, the research strategy through which the study evolved assumed a descriptive or exploratory character in order to obtain results that will usefully inform rural community education and training policy [27]. Discourses on choice of methodology in social scientific research are on going [28, 29]. For instance, some researchers have attempted to mix methods in order to expand the scope and improve the analytic power of their studies. Within this whole debate, this paper holds to Sandelwoski's thinking that the choice of methodology is dependent on the nature of research being undertaken. This reasoning drove the choice of approach in the reported study. Having said that, this paper acknowledges the existence of other approaches like experimental design that could offer insights to this study but unfortunately has a different focus and tend to suffer from being narrow in the type of information produced which makes it unsuitable for the kind of study being undertaken here. Given the exploratory nature of this study, it became essential to select a design that will accommodate the issues under investigation, hence the choice of method [30].

	Method

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In order to understand the different analytic frameworks in the reported study, mixed methods and approaches, i.e. ethnography, participatory observation and community forum, were employed to generate sufficient data and to improve its analytic power [31, 32]. If Derry [33] and McMahon's [34] views about optimal learning environment as one where a dynamic interaction between instructors, learners and tasks provide opportunities for learners to create their own truth due to their interaction with others are true, then achieving a proper understanding of social events such as the one under consideration requires a holistic approach. After all, constructivist do emphasize the importance of ‘culture’ and ‘context’ in appreciating what is happening in communities (e.g. rural communities) and constructing knowledge around existing issues [35–40].

Ethnographic approach helped in understanding existing social issues in the chosen community [41]. Participant observation created a close intimate familiarity with the community, groups and individuals like the chief, youth leader and other opinion leaders [42]. Community forum as a strategy enabled the project to remove hurdles to participation (especially in a culturally dominant society). Through the community forum technique, it made it possible for voices of people, whom hitherto would not have been heard (for whatever reason), to be recognized.

	Research design

Top Abstract Context The research setting The methods deployed to... Method Research design Results from interviews Discussion Conclusion Funding Conflict of interest statement References

 
Data gathering strategy
The research used different strategies at different stages to gather data. For instance, conversations (including interview) with the village chief were video filmed. Initial meeting with both resident dance groups was not filmed. This meeting was an opportunity to explain to all potential stakeholders within Wusuta community the research mission and objective. Upon further deliberation, the Dumas Borborbor dance group was the most preferred performing artistes. The group was presented with four themes (derived from interview data)—‘over population’, family planning, sexual immorality and environmental health—to explore whether these have roots in traditional lyrics, dance drama, proverbs and sayings.

Community forum
Palace meeting
An initial community meeting at the chief's palace was held to discuss and ascertain the level of community's knowledge on the issues under investigation [43]. This formative assessment enabled researchers to identify knowledge gaps in the issues under consideration and to tailor the educational video appropriately.

Market square meeting
The project held its first open air meeting at the market square. The reason for this meeting was to show the first edited edition of video film on the entire project—individual perceptions, group perceptions and education material by the Dumas Borborbor dance group. The project provided an electric generating machine and audio-visual equipment [44] Outcomes from that forum were revealing. For instance, there were (i) situations where both genders blamed each other for family crisis, (ii) acknowledgement that promiscuity and youth deviance were real social problems and (ii) misconceptions about family planning. The selected dance group was also observed rehearsing without being filmed [45]. The group was reminded about some key issues emerging from the palace forum which they factored into their performances. Also, two focus group interviews were held with adolescent boys and girls separately [46]. The reason for the various approaches was to triangulate data. In other words, involving multiple sources of data—opinion leaders, young people, adult men and women in the Wusuta community and drawing on secondary information. This helped to cross-check material and emerging conceptualizations, a process referred to as triangulation [47, 48].

Interviews
The in-depth interview was conducted by one researcher, while group interviews were facilitated by all three researchers. Interviews were recorded on VHS tape. In-depth interviews were held with (i) chief, (ii) young people, (iii) youth leader, (iv) opinion leaders and (v) older women. Four focus group interviews were held with adolescents (boys and girls) which were also captured on video. Results of both interviews were synthesized and grouped in themes.

Sampling strategy
The sampling strategy was purposive and mixed [49]. Community forums were based on open invitation. Data-gathering technique consisted of videotaping, group interviews and in-depth interviews with village chief, three social group leaders and one village youth leader (n = 5). There were two sets of focus group meetings with adolescent boys and girls (n = 32) [50] and two community forums (one at the chief's palace and the other at the market square) (n = 1000). Interviewees were purposely recruited. For instance, the study chose to interview the chief because of his position as custodian of community norms, values and tradition [51]. Other chosen informants were also perceived as possessing insights from different vantage points about community values, traditions and well-being. Researchers' local knowledge about community structures and organization helped in deciding who were likely to be respondents in the study. Research questions evolved around traditional perceptions about sexual promiscuity, family planning, deviance and environmental degradation; how these perceptions shape learning and behaviour among adults and young people.

Community entry and exit strategy
Formal entry into the community was preceded by an initial visit. This was a fact-finding mission and to familiarize with the community, meets opinion leaders to seek their support and mandates to stay in the community.

Researcher exit from the community was in phases. The first exit was to allow the community time to deliberate on the proposals before them and to plan for the grand production. The second exit was to allow for analysis of interview data and to edit video data before the third visit. It is important to understand that in rural communities in Ghana, video denotes ‘luxury’ where such means of education and entertainment barely exist. It is also a participatory mechanism where people are motivated by seeing themselves actively playing a role in community development, thereby indirectly empowering indigenous people to be in control of their own development, and this is exactly what happened in Wusuta. Expectations of researchers return were therefore high possibly because people wanted to see themselves in the video film. For example, researchers observed pockets of groups lingering and waving from various points along the road leading into the community during one such visit. This heralded the dissemination phase of the project.

The purpose of a third visit to the community was to watch the final version of dance drama and performance by the Dumas Borborbor group together with other members of the community. The rationale here was to produce a community educational video using folk media. The film captured the community, performers, sceneries and village infrastructure. Confidentiality was not an issue as members of the community were willing to appear in the video and purposefully positioned themselves to be filmed. This action is understood from the point of entertainment and prestige. The performances included existing rhetoric about norms, traditions and cultural values that evolved around key themes. Recitals and artistic performances were videotaped, a process familiar to Barford and Weston [52] as a useful teaching resource.

Ethical considerations
As at the time of this study, the project was not aware of any formal organization or institution responsible for research approval in Ghana. However, researcher knowledge about social research methodology and their cultural awareness provided a basis for ensuring that the project runs without hitches. For instance, researcher's fore knowledge on traditional rules which dictate that any ‘official’ visitor to the community should seek audience with community elders including the chief was valuable [53]. The chief's courtier subsequently informed other opinion leaders in the community. The research team was officially introduced to the community at the palace forum. This signified formal approval by the Chief for the project to commence in the community.

As indicated above, choice of informants was subjective as far as selecting between performing dance groups was concerned. As it were, informant selection was not done from a distance. Selection began on the second day of its consultation with the community by which time the research team would have had a good idea about who the potential respondents were. There are arguments for and against researcher familiarity with the research environment [54, 55]. The choice of Dumas Borborbor dance group over Akpene dance group infuriated the former leading them shunning the project. This, however, did not threaten the project because the Dumas group was willing to participate. Perhaps, additional artiste would have enriched the data which could have aided comparison of information gathered.

Content of final video production
The packaged production had four scenes of a total duration of 2 hours video footage. Scene 1 opens with narratives on history, culture and the socio-economic life of the community and art forms as mediums for information, education and communication. Scene 2 depicts the links between community well-being and its environment by contrasting present and past environmental conditions through traditional lyrics, drama, proverbs and sayings. Scene 3 is in a family setting. Here, the effects of ‘wrong’ (community determines what is right or wrong based on its values, norms and traditions) family and societal values are highlighted with consequences for poverty, disease, HIV/AIDS, substance abuse, deviance; crime and disrespect for authority are highlighted. Scene 4 (the concluding scene) shows community reaction to the various plots in the film, their strengths and weaknesses as a tool for community education and learning.

Video dissemination strategy
Various steps were taken to disseminate the community educational video which was produced by indigenes of the rural study community in Ghana. In the video footage, the indigenous community provided information on rural peoples' attitude, beliefs and perception about sexual promiscuity, deviance, reproductive health, family planning and environmental degradation.

There were three dissemination strategies:

(i) Screening an edited version of community video footage at the chief's palace to gauge reactions of community leaders.

(ii) Open air video screening at the market square for people to comment and react to lessons learnt from the film.

(iii) Video taping of reactions and feedback to aid further editing where necessary.

There was researcher awareness that in editing video recordings, a risk of subjective analysis of the recordings were likely. In other words, the research was faced with what to edit and what not to. Thus, only obstructive images were edited for purposes of motion uniformity and stability [56, 57]. The final video production was screened at the market square during researchers' fourth visit. The video playback session was also filmed to capture people's reaction to the video and issues discussed.

Validity and reliability of the study method
The study sought to achieve sufficient validity to allow some modest claim that the analysis has relevance beyond the immediate community in question. It tried to do this, firstly, by linking the data (from forums, interviews, video footage and focus group discussions) to a more general abstract understanding of rural community learning through folk media. The research involved multiple stakeholders—village authorities, youths and adults (both sexes) and folk media performers. The study also drew on secondary sources to help interweave different kinds of data. By using different data sources, researchers could cross-check emerging material and conceptualizations, a process referred to as triangulation (as mentioned earlier).

There is no doubt that validity is a subject of long-established debate within both qualitative and quantitative traditions. Some see the debate as a ‘methodological worry’ [58]. The debate essentially is about criteria for establishing ‘truth’ or ‘credibility’ [59]. In order to establish validity in the method used, the research linked data (interview data and video data) to a more general abstract understanding of community learning theory and participation. If reader's understanding regarding the links between community health and its well-being are correct, then the analysis offered in this project may well be applicable to other rural communities, or at least provide a useful focus for further research.

	Results from interviews

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Cross-cutting themes were evident in the interviews. These were culture, sexuality, deviance, prostitution, teenage pregnancy and crime. Emerging issues from the focus group meetings were sexuality, prostitution, irresponsibility and deviance [63]. Views from community forums were classified as adult views, young peoples' views and views from village elder (chief). The following key themes sums up data from the community project—poverty, family crisis, promiscuity, culture, deviance and family planning. Selection of data was guided by the research objective thus eliminating threats of bias. Initial challenges to the project centred on definitions of community and the selection of respondents [60].

In order to test the level of cultural sensitivity, the study brought together boys and girls in one discussion. It was found that girls were not as open on matters of sex and sexuality as they were not on their own. Boys on the other hand were articulate in their expression and sometimes ridiculed their female counterparts. This situation is a natural tension (although a setback in research settings where groups are separated by gender) because in real-life viewing of visual art/performance the audience are mixed. Lengua and Stormshak [61] found similar patterns in their research on gender differences in the prediction of coping and psychological symptoms. They argued that significant gender differences exist in the relations among gender roles and personality. This relationship did not, however, threaten the study because female participants in the other forums were articulate and provided useful information.

Popular concerns from respondent community are presented. Thus, indigenous people in Wusuta were able to point out four key themes from the final community educational video production. These are poverty, parental responsibility, deviance and need for action. Research audience in the community forum reiterated this view by recounting some difficulties they faced in rural communities:

We no longer have farm lands, so we cannot farm... peasant farming is not profitable, we are poor (Adult Woman in the Community).

Poverty no doubt has many implications for individuals and rural economies. This can create and in deed has created social problems for the people of Wusuta where parents especially abandon their family responsibility as was depicted in the video clip:

Fathers who abandon children on women bring burden to the family and society. I think that lesson is a good one (Youngman in the village).

There were also comments like:

There were good lessons from the performances. For instance we saw many children coming to their parents in tatted clothes, some feeling sick without parental support. Others scrambled for food and some were excluded from school for non payment of fees and their parents were unable to support them (Village youth leader).

If children are not taken care of they will be forced to look elsewhere for material things. This can bring about promiscuity (Adolescent female in Community).

There were also appeals for action. An example being:

If doctors (turning to researchers) can help women to have fewer children this will go a long way (Old woman in the Community).

Others in the forum were of the view that the onus lay on men to be more responsible:

If men produce many children they must help to bring up the children. Impregnating a woman goes with responsibility which our men need to understand (Woman in the Community).

Child rearing is a parental responsibility (including extended family) but its upbringing is a collective responsibility (comprising parents and wider society) in traditional societies such as Wusuta. A lack of this practice can lead to a situation where children become social liabilities with all the problems that are associated with the phenomenon. It is not surprising that those issues about deviance were of concern to the community:

The lead-singer was smoking cannabis. This is bad for young people and not a good act to depict in the performance. Smoking cannabis causes madness; young people take valium and alcohol and destroy themselves. This leads to low productivity (Chief of Wusuta)

The above concern is also a public health issue. The fact that community elders raised the subject implies a desire to address a social burden (truancy) on the community. This possibly will require a concerted effort by the community, social workers and public health officials to address the issue.

	Discussion

Top Abstract Context The research setting The methods deployed to... Method Research design Results from interviews Discussion Conclusion Funding Conflict of interest statement References

 
There is evidence to suggest that rural (follow IFAD, 2001, definition of ‘rural’) poverty is a result of multiple factors. Wusuta is just one among several rural communities in Ghana with low economic index. This may be due to many factors. For instance, the community lacks portable drinking water, good access road, electricity and social amenities. It is for this reason that readers should not see themes emerging from interview result differently from those summed in the research. The differences are more of researcher semantics than community perception. Wusuta can be classified among those Fields [62] refers to as living in poverty in sub-Saharan Africa. From participants account, a shift in focus from community action to expert-led action [63] positions the community in a ‘powerless’ situation to tackle its own problems. In other words, the community like many others lack the capacity and know how to resolve environmental tensions despite the abundance of resources which could be utilized. Perceiving the research team as ‘experts’ with a magic wand was therefore not surprising [64]. Similar lessons exist from distant projects like the Health Action Fund in the US. This is a grassroots health communications and social marketing programme that targets community groups who are involved in health promotion activities developed by large agencies. Rather than taking the traditional approach to health promotion and prevention where programme development and implementation are left to professionals, it encourages members of neighbourhoods, community groups or churches to identify a problem and then develop ways to address that problem for their group [65]. Through this approach, the community takes ownership of the learning activity and ensures that it works.

An issue about parental responsibility which was much highlighted in the community forum has force in academic discourse [66]. As Willekens notes, motherhood simply follows from the fact of giving birth to a child but paternity is ascribed on the basis of either a genetic tie with the child, the man's legal relation to the woman who has given birth to the child or a combination of the two. Once legal parenthood has been established, a right and responsibility of duties follow which seems to be lacking among some families in the Wusuta community. Indeed, parents have a duty among others to take care of the spiritual and physical well-being of the child (p. 355).

There is a privileged lesson from Apteker [67] which partly explains deviance in children in the developing world which is linked to the fact that children no longer grow up in extended families with strong community support. Mufune [68] expands this notion further by arguing that nuclear family forms are less efficient in providing for large numbers of youngsters and do not readily accommodate distant relatives. It is possible that some children in Wusuta might be victims of this order. This situation has given rise to young people who experience family crisis not to be accommodated by kinship structures. Modernization, Mufune argues, seems also to have enormous impact on children who are not prepared to adhere to parental rules and discipline (p. 239), a thinking which is corroborated by Gokah.

	Conclusion

Top Abstract Context The research setting The methods deployed to... Method Research design Results from interviews Discussion Conclusion Funding Conflict of interest statement References

 
From the above discussion, three themes reflect the essential thrust and key findings. These themes are as follows:

(i) The analytic framework in respect of community learning through video production and folk media facilitated learning and a useful resource in identifying ways in which people think and talk about the social worlds they occupy and how this affects (and is affected by) local norms and traditions, and the way values are interpreted [69]. There is evidence in academic literature to suggest that facilitated learning through video recordings of learners in action has been used in formal teaching and learning settings [70]. Its use in the informal sector to train and facilitate learning in rural communities via folk media is, however, relatively new. It thus offers opportunities to influence rural well-being [71]. Video recordings of the various stages in the study were an effective means of receiving feedback [72]. Although some studies [73] have talked about the negative effect of seeing oneself in videotapings, this was not the case in Wusuta project. The potential threat was the video footage being misconstrued as a source of entertainment (because such facilities are scarce in rural communities) over and above its educational value. Should this happen the essence of the production is likely to be missed [74]. It is difficult, if not impossible, to restrain audience participation (which includes children) in the open video forums. However, responses from those forums (as discussed earlier) indicate that the video recordings were valuable.

(ii) The community's participation in health- and environment-related learning activity was an opportunity for the people of Wusuta to ‘think through’ issues that work against their well-being. Through this mechanism, they were able to develop their own coping mechanism and ideas about resolving environmental threats. It also increased the community's desire and skills for action [75]. Community participation is a highly promoted approach by change agencies and development donors [76, 77]. In fact Chamber [78] has described community participation as ‘a growing family of approaches and methods to enable rural and urban people to express, enhance, share and analyse their knowledge of life and condition to plan and to act’. In other words, they will be able to make their own voices heard, increase their own awareness and understanding and have a role in ‘policy development’ aimed at improving their well-being. Given the link between community participation and community empowerment, it is important that the lessons from the Wusuta project are given careful attention or at least serve as a basis for further research [79].

(iii) Community learning theory has proven (in this study) to be a useful conceptual tool to explore how rural communities can be informed, educated and trained in ways to enhance or promote their well-being without necessarily relying on contemporary media—radio, television and print. Such initiatives involve the use of tested ideas and approaches to achieve intended results [80]. In order to address the complexities and challenges posed by community learning, there is need for conceptual frameworks that will link activities, outcomes and context [81]. In the Wusuta study, this took the form of gaining clarity of what community learning is all about and strategies needed to achieve learning. In generating this framework, steps were taken to link ‘problem’ with ‘context’ which helped in making explicit connection between the different components in the study and how they work. For instance, researcher's initial and continuous dialogue with stakeholders in the Wusuta community provided the fuel that sustained the research [82] and the type of information needed to establish the usefulness of folk media and self video recordings to educate rural communities. This no doubt required careful but flexible planning and adaptive approaches to rural community learning [83].

	Funding

Top Abstract Context The research setting The methods deployed to... Method Research design Results from interviews Discussion Conclusion Funding Conflict of interest statement References

 
United Nations Fund for Population Activities (UNFPA) (Ghana) and Ghana Institute of Journalism Population Communication Project.

	Conflict of interest statement

Top Abstract Context The research setting The methods deployed to... Method Research design Results from interviews Discussion Conclusion Funding Conflict of interest statement References

 
None declared.

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Top Abstract Context The research setting The methods deployed to... Method Research design Results from interviews Discussion Conclusion Funding Conflict of interest statement References

 
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Received on August 23, 2006; accepted on June 7, 2007

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