Barriers and facilitators in the provision of post-abortion care at district level in central Uganda : a qualitative study focusing on task sharing between physicians and midwives

Background: Abortion is restricted in Uganda, and poor access to contraceptive methods result in unwanted pregnancies. This leaves women no other choice than unsafe abortion, thus placing a great burden on the Ugandan health system and making unsafe abortion one of the major contributors to maternal mortality and morbidity in Uganda. The existing sexual and reproductive health policy in Uganda supports the sharing of tasks in post-abortion care. This task sharing is taking place as a pragmatic response to the increased workload. This study aims to explore physicians' and midwives' perception of post-abortion care with regard to professional competences, methods, contraceptive counselling and task shifting/sharing in post-abortion care. Methods: In-depth interviews (n = 27) with health care providers of post-abortion care were conducted in seven health facilities in the Central Region of Uganda. The data were organized using thematic analysis with an inductive approach. Results: Post-abortion care was perceived as necessary, albeit controversial and sometimes difficult to provide. Together with poor conditions post-abortion care provoked frustration especially among midwives. Task sharing was generally taking place and midwives were identified as the main providers, although they would rarely have the proper training in post-abortion care. Additionally, midwives were sometimes forced to provide services outside their defined task area, due to the absence of doctors. Different uterine evacuation skills were recognized although few providers knew of misoprostol as a method for post-abortion care. An overall need for further training in post-abortion care was identified. Conclusions: Task sharing is taking place, but providers lack the relevant skills for the provision of quality care. For post-abortion care to improve, task sharing needs to be scaled up and in-service training for both doctors and midwives needs to be provided. Post-abortion care should further be included in the educational curricula of nurses and midwives. Scaled-up task sharing in post-abortion care, along with misoprostol use for uterine evacuation would provide a systematic approach to improving the quality of care and accessibility of services, with the aim of reducing abortion-related mortality and morbidity in Uganda.

Road Design for Future Maintenance : Life-cycle Cost Analyses for Road Barriers

The cost of a road construction over its service life is a function of design, quality of construction as well as maintenance strategies and operations. An optimal life-cycle cost for a road requires evaluations of the above mentioned components. Unfortunately, road designers often neglect a very important aspect, namely, the possibility to perform future maintenance activities. Focus is mainly directed towards other aspects such as investment costs, traffic safety, aesthetic appearance, regional development and environmental effects. This doctoral thesis presents the results of a research project aimed to increase consideration of road maintenance aspects in the planning and design process. The following subgoals were established: Identify the obstacles that prevent adequate consideration of future maintenance during the road planning and design process; and Examine optimisation of life-cycle costs as an approach towards increased efficiency during the road planning and design process. The research project started with a literature review aimed at evaluating the extent to which maintenance aspects are considered during road planning and design as an improvement potential for maintenance efficiency. Efforts made by road authorities to increase efficiency, especially maintenance efficiency, were evaluated. The results indicated that all the evaluated efforts had one thing in common, namely ignorance of the interrelationship between geometrical road design and maintenance as an effective tool to increase maintenance efficiency. Focus has mainly been on improving operating practises and maintenance procedures. This fact might also explain why some efforts to increase maintenance efficiency have been less successful. An investigation was conducted to identify the problems and difficulties, which obstruct due consideration of maintainability during the road planning and design process. A method called “Change Analysis” was used to analyse data collected during interviews with experts in road design and maintenance. The study indicated a complex combination of problems which result in inadequate consideration of maintenance aspects when planning and designing roads. The identified problems were classified into six categories: insufficient consulting, insufficient knowledge, regulations and specifications without consideration of maintenance aspects, insufficient planning and design activities, inadequate organisation and demands from other authorities. Several urgent needs for changes to eliminate these problems were identified. One of the problems identified in the above mentioned study as an obstacle for due consideration of maintenance aspects during road design was the absence of a model for calculating life-cycle costs for roads. Because of this lack of knowledge, the research project focused on implementing a new approach for calculating and analysing life-cycle costs for roads with emphasis on the relationship between road design and road maintainability. Road barriers were chosen as an example. The ambition is to develop this approach to cover other road components at a later stage. A study was conducted to quantify repair rates for barriers and associated repair costs as one of the major maintenance costs for road barriers. A method called “Case Study Research Method” was used to analyse the effect of several factors on barrier repairs costs, such as barrier type, road type, posted speed and seasonal effect. The analyses were based on documented data associated with 1625 repairs conducted in four different geographical regions in Sweden during 2006. A model for calculation of average repair costs per vehicle kilometres was created. Significant differences in the barrier repair costs were found between the studied barrier types. In another study, the injuries associated with road barrier collisions and the corresponding influencing factors were analysed. The analyses in this study were based on documented data from actual barrier collisions between 2005 and 2008 in Sweden. The result was used to calculate the cost for injuries associated with barrier collisions as a part of the socio-economic cost for road barriers. The results showed significant differences in the number of injuries associated with collisions with different barrier types. To calculate and analyse life-cycle costs for road barriers a new approach was developed based on a method called “Activity-based Life-cycle Costing”. By modelling uncertainties, the presented approach gives a possibility to identify and analyse factors crucial for optimising life-cycle costs. The study showed a great potential to increase road maintenance efficiency through road design. It also showed that road components with low investment costs might not be the best choice when including maintenance and socio-economic aspects. The difficulties and problems faced during the collection of data for calculating life-cycle costs for road barriers indicated a great need for improving current data collecting and archiving procedures. The research focused on Swedish road planning and design. However, the conclusions can be applied to other Nordic countries, where weather conditions and road design practices are similar. The general methodological approaches used in this research project may be applied also to other studies.

Gravida kvinnors tankar om amning

Internationellt sett är amningsfrekvensen i dagens Sverige hög, men har minskat något senaste åren. Studier visar att inställningen till amning är positiv, men att kvinnor upplever svårigheter i samband med amning samt en brist på information och stöd. Syftet med fördjupningsarbetet var att belysa gravida kvinnors tankar om amning, amningsinformation och stöd. Studien genomfördes med kvalitativ ansats, där data samlades in genom fokusgruppsintervjuer med 18 gravida kvinnor hösten 2012. Data bearbetades med innehållsanalys. Analysen gav ett övergripande tema; Balans mellan förväntningar och svårigheter. Fem kategorier framkom; Att vara medveten om amningens fördelar, Att vara medveten om svårigheter med amning, Att planera för sin kommande amning, Att påverkas av sin omgivning och Att ha förväntningar på stöd inför kommande amning. Resultatet visade att gravida kvinnor var medvetna om amningens fördelar och svårigheter, omgivningen påverkade deras tankar och kvinnorna ansåg ofta att amningen ”löser sig naturligt”. Tydligast framkom kvinnors känsla av bristande kunskap om amningsproblem och en önskan att få amningsinformation sent i graviditet. Amningsinformation som ges under graviditet bör vara varierad, innehållsrik och förbereda föräldrarna på att amning kan vara påfrestande. Det är viktigt att involvera partnern i information och förberedelser för amning.   Nyckelord: amning, graviditet, amningsstöd, amningsinformation, amningsproblem

Barriers to adapt eCommerce by rural microenterprises in Sweden : a case study

Research has shown that small and medium-sized enterprises (SMEs) are rapidly adopting the e-commerce. However, there is nearly no research into how microenterprises are adopting eCommerce. Present paper focus on microenterprise adaption of eCommerce in terms of barriers in relation to already known research on SMEs. A case study, carried out by 12 microenterprises to find out barriers to adapt eCommerce had been done. The empirical results show that the microenterprises share most of the barriers to adapt the eCommerce with studies of SMEs, but also reveal additional factors affecting adaptation option of eCommerce; supplier agreement, communication and customer strategy. Conclusions are that microenterprises need additional support and communication and customer strategy to adapt eCommerce, depending of their requirement and needs of eCommerce.

MLCMS actual use, perceived use, and experiences of use

Mobile learning involves use of mobile devices to participate in learning activities. Most elearning activities are available to participants through learning systems such as learning content management systems (LCMS). Due to certain challenges, LCMS are not equally accessible on all mobile devices. This study investigates actual use, perceived usefulness and user experiences of LCMS use on mobile phones at Makerere University in Uganda. The study identifies challenges pertaining to use and discusses how to improve LCMS use on mobile phones. Such solutions are a cornerstone in enabling and improving mobile learning. Data was collected by means of focus group discussions, an online survey designed based on the Technology Acceptance Model (TAM), and LCMS log files of user activities. Data was collected from two courses where Moodle was used as a learning platform. The results indicate positive attitudes towards use of LCMS on phones but also huge challenges whichare content related and technical in nature.

E-learning opens the door to the global community. Novice users experiences of e-learning in a Somali University

E-learning has become one of the primary ways of delivering education around the globe. In Somalia, which is a country torn within and from the global community by a prolonged civil war, University of Hargeisa has in collaboration with Dalarna University in Sweden adopted, for the first time, e-learning. This study explores barriers and facilitators to e-learning usage, experienced by students in Somalia’s higher education, using the University of Hargeisa as case study. Interviews were conducted with students to explore how University of Hargeisa’s novice users perceived elearning, and what factors positively and negatively affected their e-learning experiences. The Unified Theory of Acceptance and Use of Technology (UTAUT) model was used as a framework for interpreting the results. The findings show that, in general, the students have a very positive attitude towards e-learning, and they perceived that e-learning enhanced their educational experience. The communication aspect was found to be especially important for Somali students, as it facilitated a feeling of belonging to the global community of students and scholars and alleviated the war-torn country’s isolation. However, some socio-cultural aspects of students’ communities negatively affected their e-learning experience. This study ends with recommendations based on the empirical findings to promote the use and enhance the experience of e-learning in post conflict Somali educational institutions

'They would never receive you without a husband' : Paradoxical barriers to antenatal care scale-up in Rwanda

OBJECTIVE: to explore perspectives and experiences of antenatal care and partner involvement among women who nearly died during pregnancy ('near-miss'). DESIGN: a study guided by naturalistic inquiry was conducted, and included extended in-community participant observation, semi-structured interviews, and focus group discussions. Qualitative data were collected between March 2013 and April 2014 in Kigali, Rwanda. FINDINGS: all informants were aware of the recommendations of male involvement for HIV-testing at the first antenatal care visit. However, this recommendation was seen as a clear link in the chain of delays and led to severe consequences, especially for women without engaged partners. The overall quality of antenatal services was experienced as suboptimal, potentially missing the opportunity to provide preventive measures and essential health education intended for both parents. This seemed to contribute to women's disincentive to complete all four recommended visits and men's interest in attending to ensure their partners' reception of care. However, the participants experienced a restriction of men's access during subsequent antenatal visits, which made men feel denied to their increased involvement during pregnancy. CONCLUSIONS: 'near-miss' women and their partners face paradoxical barriers to actualise the recommended antenatal care visits. The well-intended initiative of male partner involvement counterproductively causes delays or excludes women whereas supportive men are turned away from further health consultations. Currently, the suboptimal quality of antenatal care misses the opportunity to provide health education for the expectant couple or to identify and address early signs of complications IMPLICATIONS FOR PRACTICE: these findings suggest a need for increased flexibility in the antenatal care recommendations to encourage women to attend care with or without their partner, and to create open health communication about women's and men's real needs within the context of their social situations. Supportive partners should not be denied involvement at any stage of pregnancy, but should be received only upon consent of the expectant mother.

Effects of computer reminders on complications of peripheral venous catheters and nurses' adherence to a guideline in paediatric care : a cluster randomised study

BACKGROUND: Reminder systems in electronic patient records (EPR) have proven to affect both health care professionals' behaviour and patient outcomes. The aim of this cluster randomised trial was to investigate the effects of implementing a clinical practice guideline (CPG) for peripheral venous catheters (PVCs) in paediatric care in the format of reminders integrated in the EPRs, on PVC-related complications, and on registered nurses' (RNs') self-reported adherence to the guideline. An additional aim was to study the relationship between contextual factors and the outcomes of the intervention. METHODS: The study involved 12 inpatient units at a paediatric university hospital. The reminders included choice of PVC, hygiene, maintenance, and daily inspection of PVC site. Primary outcome was documented signs and symptoms of PVC-related complications at removal, retrieved from the EPR. Secondary outcome was RNs' adherence to a PVC guideline, collected through a questionnaire that also included RNs' perceived work context, as measured by the Alberta Context Tool. Units were allocated into two strata, based on occurrence of PVCs. A blinded simple draw of lots from each stratum randomised six units to the control and intervention groups, respectively. Units were not blinded. The intervention group included 626 PVCs at baseline and 618 post-intervention and the control group 724 PVCs at baseline and 674 post-intervention. RNs included at baseline were 212 (65.4 %) and 208 (71.5 %) post-intervention. RESULTS: No significant effect was found for the computer reminders on PVC-related complications nor on RNs' adherence to the guideline recommendations. The complication rate at baseline and post-intervention was 40.6 % (95 % confidence interval (CI) 36.7-44.5) and 41.9 % (95 % CI 38.0-45.8), for the intervention group and 40.3 % (95 % CI 36.8-44.0) and 46.9 % (95 % CI 43.1-50.7) for the control. In general, RNs' self-rated work context varied from moderately low to moderately high, indicating that conditions for a successful implementation to occur were less optimal. CONCLUSIONS: The reminders might have benefitted from being accompanied by a tailored intervention that targeted specific barriers, such as the low frequency of recorded reasons for removal, the low adherence to daily inspection of PVC sites, and the lack of regular feedback to the RNs. TRIAL REGISTRATION: Current Controlled Trials ISRCTN44819426.

Facilitators and barriers to applying a national quality registry for quality improvement in stroke care

BACKGROUND: National quality registries (NQRs) purportedly facilitate quality improvement, while neither the extent nor the mechanisms of such a relationship are fully known. The aim of this case study is to describe the experiences of local stakeholders to determine those elements that facilitate and hinder clinical quality improvement in relation to participation in a well-known and established NQR on stroke in Sweden. METHODS: A strategic sample was drawn of 8 hospitals in 4 county councils, representing a variety of settings and outcomes according to the NQR's criteria. Semi-structured telephone interviews were conducted with 25 managers, physicians in charge of the Riks-Stroke, and registered nurses registering local data at the hospitals. Interviews, including aspects of barriers and facilitators within the NQR and the local context, were analysed with content analysis. RESULTS: An NQR can provide vital aspects for facilitating evidence-based practice, for example, local data drawn from national guidelines which can be used for comparisons over time within the organisation or with other hospitals. Major effort is required to ensure that data entries are accurate and valid, and thus the trustworthiness of local data output competes with resources needed for everyday clinical stroke care and quality improvement initiatives. Local stakeholders with knowledge of and interest in both the medical area (in this case stroke) and quality improvement can apply the NQR data to effectively initiate, carry out, and evaluate quality improvement, if supported by managers and co-workers, a common stroke care process and an operational management system that embraces and engages with the NQR data. CONCLUSION: While quality registries are assumed to support adherence to evidence-based guidelines around the world, this study proposes that a NQR can facilitate improvement of care but neither the registry itself nor the reporting of data initiates quality improvement. Rather, the local and general evidence provided by the NQR must be considered relevant and must be applied in the local context. Further, the quality improvement process needs to be facilitated by stakeholders collaborating within and outside the context, who know how to initiate, perform, and evaluate quality improvement, and who have the resources to do so.

Knowledge translation in Uganda : a qualitative study of Ugandan midwives' and managers' perceived relevance of the sub-elements of the context cornerstone in the PARIHS framework

BACKGROUND: A large proportion of the annual 3.3 million neonatal deaths could be averted if there was a high uptake of basic evidence-based practices. In order to overcome this 'know-do' gap, there is an urgent need for in-depth understanding of knowledge translation (KT). A major factor to consider in the successful translation of knowledge into practice is the influence of organizational context. A theoretical framework highlighting this process is Promoting Action on Research Implementation in Health Services (PARIHS). However, research linked to this framework has almost exclusively been conducted in high-income countries. Therefore, the objective of this study was to examine the perceived relevance of the subelements of the organizational context cornerstone of the PARIHS framework, and also whether other factors in the organizational context were perceived to influence KT in a specific low-income setting. METHODS: This qualitative study was conducted in a district of Uganda, where focus group discussions and semi-structured interviews were conducted with midwives (n = 18) and managers (n = 5) within the catchment area of the general hospital. The interview guide was developed based on the context sub-elements in the PARIHS framework (receptive context, culture, leadership, and evaluation). Interviews were transcribed verbatim, followed by directed content analysis of the data. RESULTS: The sub-elements of organizational context in the PARIHS framework--i.e., receptive context, culture, leadership, and evaluation--also appear to be relevant in a low-income setting like Uganda, but there are additional factors to consider. Access to resources, commitment and informal payment, and community involvement were all perceived to play important roles for successful KT. CONCLUSIONS: In further development of the context assessment tool, assessing factors for successful implementation of evidence in low-income settings--resources, community involvement, and commitment and informal payment--should be considered for inclusion. For low-income settings, resources are of significant importance, and might be considered as a separate subelement of the PARIHS framework as a whole.

Lessons learned from stakeholders in a facilitation intervention targeting neonatal health in Quang Ninh province, Vietnam

BACKGROUND: In northern Vietnam the Neonatal health - Knowledge Into Practice (NeoKIP, Current Controlled Trials ISRCTN44599712) trial has evaluated facilitation as a knowledge translation intervention to improve neonatal survival. The results demonstrated that intervention sites, each having an assigned group including local stakeholders supported by a facilitator, lowered the neonatal mortality rate by 50% during the last intervention year compared with control sites. This process evaluation was conducted to identify and describe mechanisms of the NeoKIP intervention based on experiences of facilitators and intervention group members. METHODS: Four focus group discussions (FGDs) were conducted with all facilitators at different occasions and 12 FGDs with 6 intervention groups at 2 occasions. Fifteen FGDs were audio recorded, transcribed verbatim, translated into English, and analysed using thematic analysis. RESULTS: Four themes and 17 sub-themes emerged from the 3 FGDs with facilitators, and 5 themes and 18 sub-themes were identified from the 12 FGDs with the intervention groups mirroring the process of, and the barriers to, the intervention. Facilitators and intervention group members concurred that having groups representing various organisations was beneficial. Facilitators were considered important in assembling the groups. The facilitators functioned best if coming from the same geographical area as the groups and if they were able to come to terms with the chair of the groups. However, the facilitators' lack of health knowledge was regarded as a deficit for assisting the groups' assignments. FGD participants experienced the NeoKIP intervention to have impact on the knowledge and behaviour of both intervention group members and the general public, however, they found that the intervention was a slow and time-consuming process. Perceived facilitation barriers were lack of money, inadequate support, and the function of the intervention groups. CONCLUSIONS: This qualitative process evaluation contributes to explain the improved neonatal survival and why this occurred after a latent period in the NeoKIP project. The used knowledge translation intervention, where facilitators supported multi-stakeholder coalitions with the mandate to impact upon attitudes and behaviour in the communes, has low costs and potential for being scaled-up within existing healthcare systems.