Understanding the Contextual Factors Affecting Women’s Health in Sistan and Baluchestan Province in Iran: A Qualitative Study

ABSTRACT

Background:

Contextual factors impact health the same way social and cultural conditions do. Women’s health, with its varying dimensions, is also under the influence of biological, societal, and cultural contexts. This typical condition has been developed along the continuum of their life cycle, bearing close correlation with their lif style. Therefore, identifying those marices within which women’s health behaviors are formed is important.This study aims at exploring the contextual factors affecting women’s health in Sistan and Baluchestan in Iran.

Methods:

This study was carried out using a qualitative method, on a content analysis approach. Participants were 20 middle-aged women from Zahedan who entered the study with purposive sampling method. The method of collecting data was face-to- face and through conducting semi-structured interviews. After data collection, all interviews were transcribed, andreviewed, from which categories were extracted. The semantic similarities were revised and subcategories were identified, and then the related subcategories were arranged under one category.

Results:

Two main categories of “features of context-based structure” and “changes in the cultural context” prove to be the basis for health behaviors in women. As for the category of “characteristics of context-based structure”, individual, familial and environmental characteristics were identified, and regarding the category of “changes in the cultural context”, the context-based cultural features were identified.

Conclusion:

The findings of the study suggest that effective contextual factors influencing women’s living conditions had a decisive role in their health behaviors. In fact, the context- based structure in association with the cultural changes that have occurred in the beliefs of men and women, have had a decisive role in the women’s health behaviors.

INTRODUCTION

Good health is the basic human right in all its facets. Health and welfare systems of the world tend to promote their goal of providing health care to the creation of a healthy society more than ever. Women’s health in addition to biological characteristics is influenced by cultural and social factors.¹ At the same time, understanding the issue of health, far more than the biological differences between men and women is influenced by cultural-social issues. As a matter of fact, the social structure of gender determines the views, attitudes, behavior and roles defined for both men and women. Gender affects all aspects of women’s lives, needs, opportunities and their access to health resources.²

However, women’s health is intertwined with physical, psychological, social, cultural and spiritual aspects determined by biological, social, political and economic contexts which are prevalent in the form of a continuum all along their life cycle, bearing too close a relationship with their living conditions. Therefore, it is highly important to try to attend to women’s health issues during their life cycle.^1-3 For example, menstruation, being a physiological process, was referred to as the socio-cultural taboo in a study which caused specific restrictions for women both socially and culturally.⁴ In another study, women referred to postmenopausal as a freedom period.⁵ This is despite the fact that women in Iran and Turkey were trying to conceal menopause, deemed it the end of femininity and youth.^6,7 In a study in which the participants were female householders, the variety of roles that they played proved to be a deterrent to their health.⁸ In another study, middle-aged women considerd physical changes as the inhibiting factors to mental health.⁹

However, women do deserve the right to enjoy the highest level of good health attainment on its varying dimensions, e.g. physical, psychological, social, cultural, which requires their having access to information, care-provisions, and health-treatment services.¹⁰ Middle age is one of the stages of women’s life. Middle-aged period ranges from 40-65 years of age. A typical feature of healthy middle-agedness is to enjoy physical health associated with positive mental energy. The results of studies on health issues show that no comprehensive studies have yet been done on identifying the aspects of women’s health over different age periods.^1,4 However, it seems that the problems associated with middle-aged women’s mental health are on the increase.¹⁰ In addition, findings of a study in which the participants were middle-aged women, showed that they were exposed to different emotional and mental harassments over this age period with no buffer to serve against it.¹¹

To the World Health Organization, However, good health is the most important indicator of development of countries, and factors affecting women’s health in different age groups should be taken into account. One of the greatest responsibilities of nurses is health promotion. The concept of health, one of the leading metaparadigms in nursing, and nursing is a health-based discipline.¹² Therefore, nurses should be able to understand people’s conditions if they want to help maintain and improve their health. Moreover, from the perspective of women or consumers of health services, as findings of a qualitative study in Peru showed, failure to use screening programs for breast cancer, despite the availability of facilities, is their distrust towards the medical staff.¹³

Factors such as social and cultural status affect good health; thus, the city of Zahedan, the capital of Sistan-Baluchistan province was considered the focus of research, as it is quite different socially, culturally, economically and climatically from the rest of the country. This province is geographically located in the southeast of Iran, and enjoys special political, cultural, social and health-wise status due to its geographical location and its closeness to both Pakistan and Afghanistan. In addition, the heat and sand storms mark the special climatic characteristics of this province. According to the 2011 census of Iran Statistical Center, the province, compared to other provinces, has the highest household size (4.3), the lowest level of literacy (71.6) and the lowest rate of urbanization (%40). Zahedan, the provincial capital, is made up of Sistani, Balochi and Persian ethnic groups that have certain customs and culture. The city, due to its being centrical, has undergone social and cultural changes more than other regions in the province. Reseach results in the area of health indicate that the province does not hold favorable standing insofar as the results of a study conducted on the women in Zahedan revealed that the menopause age in the women under study was lower as compared to other women studied in other researches; and their social and economic status was associated with menopause. It would be a function of nutritional status, cultural factors and a series of other unknown social and economic variables.¹⁴ For this reason, contextual identification within which women’s health behaviors are formed is important.

Conducting qualitative methods, given the nature, can clarify the underlying contextual factors affecting health; or, in other words, can lead to the identification of facilitators and deterrents affecting women’s health as viewed by them. Therefore, some of the context- based factors including society and culture affect women’s health concept. As mentioned earlier, problems associated with women’s health must be identified by themselves and with regard to the degree of control they have over their lives¹. Therefore, this study aimed to understand the contextual factors affecting Sistani and Baluchestani women’s health.

MATERIALS AND METHODS

Study Design

This research is a qualitative study using content analysis. Content analysis in three stages was performed¹⁵. In the preparation phase, texts were read several times while in the organization phase, focus was on semantic units and extracting primary codes. At this stage duplicated codes were removed to reduce the codes. Then, catagories and sub-catagories were created by classifying the codes. Finally, the themes were extracted. There porting phase began afterwards and resulted in a good set of themes, which were then written and reported as the final analysis. Interviews continued until data saturation.

In this study, participants were selected through purposive sampling. Sampling was done among Sistani and Baluchi women, residing in Zahedan, with maximum variation in the level of education, marital status and job until data saturation. It should be noted that women who were not residants of Sistan & Baloushestan province were not included in the study. The data saturation is when the researcher does not receive any more new points and the information received from the participants is repetitive. This study was conducted with the participation of 20 women. The selection criterion for women wasbeing middle-aged (40-60 years of age). Reluctancy was considered a criterion to avoid participation. The focus of interview, proportional to qualitative research method, was a natural setting that would enable access to middle-aged women. To this end, interviews were conducted in areas such as home or workplace. The data collection stage lasted for 3 months from March 2015 to July 2015.

Collecting data was carried out through face-to- face and semi-structured interviews. Furthermore, notes in the field were used for better identification of the context. First, a general question was asked “what kinds of contextual factors affect your health?” to gain more information, the interview went on with follow-up questions such as “What do you mean by that?” or “please explain that further?” .The duration of each interview was between 30-45 minutes. Interviews were digitally recorded with the informed consent of the participants. Each participant was interviewed just once; so 20 interviews were done.

Data analysis took place concurrent with data collection using the conventional content analysis method. The interviews, texts, and field notes were handwritten on paper and then typed up. The interview texts were perused several times and were broken into constituting units of meaning and codes. The codes were then re-read in order to be placed under subcategories and main categories on the basis of semantic similarity. The researcher also tried as much as possible not to introduce his/her presumptions into the process of data analysis.

To ensure the rigor of the data, measures of credibility, dependability, confirmability and transferability were used¹⁶ Parallel with dependability of the data, the inquiry audit method was applied; to do so, interviews and codes were rechecked by research colleagues to adopt interpratations and meanings and one independent supervisor, who was fully conversant with both women’s healthcare issues and qualitative research, but was not part of the research team, was called in, and there was a consensual view about the results. All activities were recorded in order to confirm the confirmability of the findings, and one report on the investigation process was prepared. To determine the transferability of the data, the results were discussed and verified with two middle-aged women, who were not part of the study, yet involved in similar situations like those of the participants. There was an ongoing working with both the subject and the data. The research team’s comments in relation to the process and analysis of the data were taken into account. The interviews, texts, and extracted codes as well subcategories were shared with some of the participants.

In addition to presenting information to the participants about the purpose of the study, the researcher was given oral consent by the participants and the participants were assured that this information would remain confidential in accordance with the ethical considerations. They were also told that they could withdraw from the research any time they wished to be excluded. All of the participants orally confirmed their consent to be interviwed. This article was supported by Zahedan University of Medical Sciences with the research ID: ir.zaums.rec.1395.20

RESULTS

Profiles of the participants in this study are presented in Table 1.

Table 1.

Demographic Profile of Participants

Code	Marital Status	Age (YEAR)	Number of Children	Education	Occupation	Ethnicity
1	Married	44	2	Bachelor	Employed	Sistāni
2	Divorced	46	1	Graduand	Housewife	Sistāni
3	Single	48	-	Diploma	Employed	Sistāni
4	Married	49	2	Bachelor	Employed	Sistāni
5	Married	45	2	Associate Degree	Employed	Sistāni
6	Married	53	6	Illiterate	Housewife	Baluch
7	Married	49	4	Graduand	Employed	Sistāni
8	Widow	51	5	Illiterate	Housewife	Baluch
9	Married	56	3	Associate Degree	Retired	Sistāni
10	Married	56	3	Diploma	Employed	Baluch
11	Married	43	2	MA	Employed	Sistāni
12	Single	41	-	MA*	Employed	Sistāni
13	Single	41	-	Bachelor	Employed	Sistāni
14	Single	45	-	Associate Degree	Employed	Baluch
15	Married	40	1	MA	Employed	Baluch
16	Married	43	2	Bachelor	Employed	Sistāni
17	Married	49	2	Bachelor	Employed	Sistāni
18	Married	38	-	Bachelor	Employed	Baluch
19	Single	40	-	General Practitioner	Employed	Sistāni
20	Married	40	8	Illiterate	Housewife	Baluch

^*Master of Art

Two categories “features of the context-based structure “and “changes in the cultural context” were identified as the contextual factors influencing health behaviors in women (Table 2).

Table 2.

Shows the main categories, sub-categories and the guiding codes

Categories	Subcategories	Guiding Codes
Features of context- based structure	Individal understands of oneself	Knowing one’s characteristics
		Perceiving work conditions
	Family atmosphere	Family circumstances
		Family support resources
	Environmental features	Climatic challenges
		Sports facilities
		Limited medical resources
Changes in the cultural context	Existing cultural conditions	Cultural beliefs of the community
		Consanguineous marriage Challenges
	Transformation of culture	Changes in women’s beliefs
		Changes in men’s attitudes towards women

• 1. Features of the context-based structure: as for the context-based structure, micro and macro conditions are identified in the form of personal, family and environmental contexts. Micro features include the individal’s understanding of oneself and the family atmosphere; and Macro featuress encompass environmental conditions such as climatatic challenges, sports facilities and limited medical resources.

• 1.1. Individal Understanding of oneself: people plan and follow their health programs based on their understanding of individual characteristics and conditions. One participant said, “they tell me that I am too fastidious, and sensitive, but I can not go carefree ... I know it is a flaw and should take it easier a little bit, and I don’t. Well, I can not do anything, for I grew up like that until reaching that age. ...” (Married, 45 y/o).

  Another participant stated that: “... I feel a lot better…. well, the older one gets, the better one can sort things out. At a younger age one is easily impressed, and gets the jitters, now I am much improved. When something annoys me I find myself pondering the question for an hour, then I forget it ... “(Married, 56y/o). Another participant told us about her work: “….it feels like awesome working at this age; when I chat with other women about the things happened, I do forget those annoying stuff way quicker...” (Single, 48 y/o).

• 1.2. Family Atmosphere: certain conditions govern families, including children’s age characteristics, spouse’s attributes and responsibilities that women bear at home with their family support resources. One participant said about the family atmosphere in this way: “I get a good feeling any time kids give me a hand with the household chores; for instance, when I get back home from work and the lunch is ready….well… it radiates a comforting sense. I thank God, for there is someone out there to help me” (Married 44y/o)

  Also, one participant regarded father’s family (paternity) as a source of psychological support. She said: “... my father’s family understood me very well, of course, they can not support me financially, but they do psychologically. They help me out when I am sick or when I’m alone or when my husband is away and has to do lots of homework“(Married, 43y/o).

• 1.3. Environmental Characteristics: climate challenges, sports facilities and limited medical resources were among other factors that influence women’s health behaviors. On the climate challenges, one participant stated: “... I must admit that I am used to living in this town and living in this kind of climate and I’m not protesting and not bothered. I was born and lived here and I am used to it. When the weather is bad, I do work out my plan. I commute mostly by car, and do not get out when the heat is at its peak. I go out in the evening when it is cool outside. I do my chores in the evenings....’’ (Married, 49y/o).

  Sports facilities were other features of the structure of the context which played a role in the behaviors leading to preserving and promoting women’s health. The husband of one of the women said: “... it’s now two or three years that my wife goes hiking. Recently, a decent track has been made for hiking in our neighborhood, and all women of the same age as my wife go for a walk there. Such a facility has created motivation in them’’ (Married, 49y/o).

  Limited medical resources form another environmental condition of the context-based structure. One participant stated in this regard: “... I was admitted to one of the hospitals for having a heart condition. If you have any contact in hospitals, you will be taken care of, if not, you won’t. I was sort of pampered on the recommendation of my contacts. But if there is no body out there to recommend you, no body will care at all, in particular, in state hospitals; private hospitals are not available in here”(Married, 56y/o).

• 2. Changes in the Cultural Context: the context with its intrinsic specific cultural characteristics was an influencing factor on women’s health behaviors.

• 2.1. Existing Cultural Conditions: a set of cultural conditions governing the community that affects many of women’s behavior, in line with maintaining and promoting their good health. Adherence to traditions, giving priority to consanguineous, permanent hospitality of the family, and the culture of polygamy were such cases of which consanguineous marriage brought many challenges for women. On the issue of consanguineous (cousin) marriage and its concomitant challenges, one participant stated: “... I am married to a blood relative and am affected by this condition, because we’re relatives. I have more interaction with my spouse’s family, see them more often than not, spending more time with themand in case of any misunderstanding, it will affect many and it depletes you of positive energy, ruining both physical and mental health…” (Married, 43y/o). Another participant touched on the issue of cousin marriage in this way: “My sister-in-law’s marriage is not a cousin marriage. When we talk together and I compare my life with hers, I notice that I have more problems because I am dealing with problems with both maternal and paternal uncles as well as other relatives. But she is relieved of all such problems because the family is not involved, but I am too much involved ...” (Married, 43y/o).

  On the subject of the culture of hospitality, which had an impact on her health, the same participant said: “... We have too many guests, even on Thursdays and Fridays. We have guests all the time. These are all decisive in not allowing me to think about my health ...” (Married, 45y/o).

  Another participant on the subject of the culture of polygamy, said: “... I am the only wife of my husband. Some men marry 2 or 3 wives, well…. this is not good ...” (Married, 53y/o).

• 2.2. Transformation of culture: this sub-category or its instances such as a change of attitude towards adherence to customs, popular sentiment toward the conventional issues fading, intolerance of spouse’s second marriage, and interacting with people of the same type were identified. Moreover, on the issue of change in cultural beliefs, change in the attitude of men was also identified of which things like gradual disappearance of the culture of polygamy, a change in their attitude toward women’s health, and change of attitude to continuing studies were noted. One participant said: “...with the -grown-up generation not intending to stick to the old prejudices, perhaps the culture of monogamy is growing into this culture ......those who are polygamous are not pretty much into the financial aspects, they just want to adopt two or three wives the way their fathers did, or when speaking about polygamy they say we are not in the mood. Therefore, I feel that the culture of polygamy is fading out….’’ (Married, 40y/o).

  On the issue of interacting with people with similar likes, appearance or behavior, another participant said: “I’d love to hang around with people of my own personality type to chat, laugh and talk about good things. These people are like me, they get a kick out of evrytthing. Ironically, for example, I went to Chabahar with my relatives in Chabahar; when we got back, they said it was bad, but I said it was like heaven. All these things influence me so I can’t be close to such people ...” (Married, 56y/o).

DISCUSSION

Features of the context-based structure” and “changes in the cultural context” were the main categories monitoring the context which played a role in the formation and strength of the health behaviors of the Sistani and Baluchi women. The current study showed that the individual’s self-perception, or features such as understanding the traits of one’s character and understanding the working conditions associated with the family atmosphere as well as the environmental properties and characteristics affect women’s health so much that some participants attributed the psychological strain and fatigue to work and some believed it would be conducive to health. In a separate study, women took it for granted that social and civic engagement proved to be positive in enhancing and improving their health.¹⁷ What is more, in this study, women pointed to different personal characteristics they exhibited in different situations. Of these to enumerate werebeing strict and sensitive in doing things, feeling satisfied with being popular and having diversified concerns. It seems women’s being aware of their personality traits affects their behavior and actions. The literature review showed that some personality traits of the women such as troubles in mind and those concerns resulting from other physical conditions have been addressed. Much of these concerns and worries are caused by menopause as the end of femininity.^7,18 In one study, specific characteristics of Iranian women, i.e. low self-confidence, was noted as the factor affecting the mental health1. However, diverse personality traits in women seem to affect their health behaviors.

Family atmosphere was another feature of the context-based structure. Family atmosphere encompasses conditions governing the family as well as the family support resources that women face head-on in the family. In this study, participants pointed to a few circumstances governing families, such as the way children are brought up, spouse’s characteristics, and tasks for which they are chiefly responsible.The literature review showed that children can play an important role in the ups and downs of women’s life.¹⁹ In addition, not only can the spouses participate in roles such as family planning, but also they can cause domestic violence against women. In this regard, studies conducted in the country stressed on the role of men as responsible for women’s health.^20-22 The results of a study which focused on egytianthe extended family resources indicated that spouses were responsible for women’s.²³ At the same time, the results of a study in which the participants were middle-aged women in Yazd indicated thatmen’s domination was the major obstacle facing women’s health.²⁴ Research findings on family planning in Tanzania showed that men had no interest in participating in family planning due to the culture of domination.²⁵ The findings of a study also showed that in Kosovo patriarchal culture leads to domestic violence against women due to gender roles in that society.²⁶ The literature review confirms that men have an important role in women’s health. Thus, women’s health promotion is subject to the participation of women in healthcare programs

Multiple responsibilities that women undertake in different life situations add to their tasks and duties. The cases that the study participants pointed to were such as having a child contracting certain diseases, taking care of grandchildren and being the heads of the family. The present study revealed that these factors led to the women’s failiure in affording or devoting time to their health. In this regard, the result of a study on Canadian middle-aged women showed that time limitation was the obstacle making them do regular exercise.²⁷ In a study on the female heads of household, the responsibility was regared as one of the responsibilities imposed.The responsibilities had limitation on time and financial resource as well as energy depletion for them.^1,8

Family support resources mark another feature dominating the family, havhng an impact on women’s health behaviors. In the present study, women’s support resources within the family have been associated with a range of positive and negative aspects of support from children, spouses and other family members. As related to the women’s support resources, studies have indicated that the supportive aspects for women have been on the focal point mostly at the time of their exposure to diseases such as breast cancer.^18,28 They also asserted that they needed support and attention by their spouses when faced with menopause, which is associated with physical and psychological problems for them.⁶ The findings of a study on Swedish women participants showed that family support has had an effective role in the implementation of weight loss program.²⁹ The findings of a study in Egypt revealed that women’s support resources are highlighted more in relation to physical problems, and spouses as well as next of kins were their support feeders.²³ Canadian women had reported loneliness as one impediment to the promotion and preservation of their health.³⁰ However, family atmosphere, which is one of the features representing the context-based structure in the current research, showed that family is highly significant in women’s health.

Environmental features are among other characteristics of the context-based structure which determine the formation of women’s health behaviors. Environmental features encompassed cases such as climatic challenges, sports facilities and limited treatment resources available. Participants in this study considered the climatic conditions as a context impacting their health. The literature review showed that climate can affect health behaviors including eating habits and clothing.³¹ revealed by the observations that emerged from the current study, limited access to vegetables is the main challenge for women. In addition, women’s covering, i.e. use of burka, sun glasses, and hand gloves as a protection against sunshine, showed that women use protective gadgets in a bid to keep their skin and eyes healthy. The Eastern Asian women living in Australia did protect their skin against sunshine, despite concomitant physical problems such as shortage of vitamin D.³¹ study conducted in one state of India indicated thatwater shortage was known to be a major climate-related problem in the way of physical, mental and social health. This problem led to the emergence of conditions such as increased susceptibility to disease, migration and domestic violence.³²

Sports facilities marked another aspect of the environmental feature embedded into the context-based structure. Participants in this study raised a range of comments from satisfaction to dissatisfaction with the existing sports facilities in the context; womenpointed to lack of amenities such as places designated for walking, sports facilities, and suitable places for walking. Literature review indicated that provision of facilities has had a significant role in creating positive view towards exercise.³³ By the same token, research findings confirmed that kinetic disorders in the middle-aged women stemmed from limited facilities during previous stages of their life¹. These deficiencies were identified as social barriers facing women’s health as revealed in a study.^24,34

Limited medical resource was another aspect of the environmental feature grown into the context-based structure. What was gained out of the current study as to the limited medical resources was the experience and understanding of women of the available medical facilities. This understanding bore close relations with their medical experiences. In another study, women reported on the limited environmental resources as a barrier to preventive behaviors.^12,35 The findings of a research on Baluchi women from Zahedan, as participants, noted that the failure to refer women to treatment centers for a safe delivery was the treatment crews’ ignorance of cultural and religious issues.³⁶ In a study carried out in Peru, obstacles to patients’ referral to treatment centers in the states, being examined by a specialist, improper behavior by physicians, and sistrust of the treatment systems were identified.^12,14

The existing cultural conditions along with cultural beliefs subject to change have brought about the possibility of changing the cultural context by the passage of time. Therefore, it can be argued that the existing cultural conditions or typical characteristics such as those beliefs governing the society and cousin marriages are tied to instances like adhering to polygamy, permanent hospitality, or, in other words, nonstop commuting of the family members. In addition, consanguineous marriage with its own tensions, such as more interaction with family, led to the existing cultural conditions owing to a wide range of misunderstandings, conflicts with the spouse and family stress. The literature review showed that such cultural beliefs could influence the fate of Iranian and Punjabi women in their struggle against problems such as breast cancer.^28,37 is obvious that the root of succumbing to fate is geared to the Muslims’ religious beliefs, making it easier for them to accept harsh conditions.

Parallel to the subcategory ofexisting cultural conditions, another subcategory emerged, which is “transformation of culture”. Participants in the current study touched on issues such as change of view towards adherence to customs, fading focus on conventional notions, nontolerance of spouse’s second marriage, twist in women’s hobbies, and domination of sports spirit on them. Thses ranges of changes in the context paved the way for relative autonomy, more communication with people of the same type and modifying visits with and from relatives. At the same time, changes in the attitudes of men such as, fading culture of polygamy, a change in their view toward women’s health and continued studies have had an important role in creating cultural changes. In line with prevailing cultural issues, some studies have identified factors such as cultural and sexual prejudice and male dominance as the barriers facing women’s health.^24,38 results of one study in Tanzania revealed that not only did the culture of men’s dominance affect women’s health, but also it overshadowed the health of the society to the extent that men were not willing to take part in the family planning session.²⁵ The findings of a study conducted based on the changed attitude of men revealed that efforts towards changing men’s views were only directed at their participation in the family planning sessions, and the role of mass media.^20,21 Moreover, results of a study conducted on Swedish and Tanzanian women showed that sex orientations have always been obstacles to women’s health.²⁹ The literature review confirms that men are involved in women’s health while promoting women’s health in the family is subject to cultural changes and shift of attitudes in men. This study also revealed that changes in cultural biases significantly influences health behaviors among women.This study, presents new information about factors affecting middle-aged women’s health; factorswhich have been neglected in women’s health planning based on the cultural context and structure.

In this study, like other qualitative studies, generalizability is impossible due to low proportion of participants, which is considered one of the limitations of the research. The participants of the present study had their own limitations to be interviewed since they were engaged in numerous commitments.

CONCLUSION

This study clarified that context- based structure or changes with their cultural background had a determining role in shaping up women’s health behaviors. In fact, it became clear that context- based structures influence those behaviors leading up to the preservation and promotion of health in women under micro and macro conditions. It seems that the structural changes were shaped according to changes in the cultural views in women. Furthermore, the struggles of women in maximum use of minimal resources were pivoted round the motion to change conditions. In this study, it became crystal-clear that women’s health behaviors, context- based structure characteristics, especially changes in the context, have had an important role. The research team suggests the contexts to be identified by ethnographic approaches which would be more efficient to identify contextual factors.