Negotiating collective and individual agency : a qualitative study of young women's reproductive health in rural India

The societal changes in India and the available variety of reproductive health services call for evidence to inform health systems how to satisfy young women's reproductive health needs. Inspired by Foucault's power idiom and Bandura's agency framework, we explore young women's opportunities to practice reproductive agency in the context of collective social expectations. We carried out in-depth interviews with 19 young women in rural Rajasthan. Our findings highlight how changes in notions of agency across generations enable young women's reproductive intentions and desires, and call for effective means of reproductive control. However, the taboo around sex without the intention to reproduce made contraceptive use unfeasible. Instead, abortions were the preferred method for reproductive control. In conclusion, safe abortion is key, along with the need to address the taboo around sex to enable use of "modern" contraception. This approach could prevent unintended pregnancies and expand young women's agency.

Factors facilitating a national quality registry to aid clinical quality improvement : findings of a national survey

Objectives: While national quality registries (NQRs) are suggested to provide opportunities for systematic follow-up and learning opportunities, and thus clinical improvements, features in registries and contexts triggering such processes are not fully known. This study focuses on one of the world's largest stroke registries, the Swedish NQR Riksstroke, investigating what aspects of the registry and healthcare organisations facilitate or hinder the use of registry data in clinical quality improvement. Methods: Following particular qualitative studies, we performed a quantitative survey in an exploratory sequential design. The survey, including 50 items on context, processes and the registry, was sent to managers, physicians and nurses engaged in Riksstroke in all 72 Swedish stroke units. Altogether, 242 individuals were presented with the survey; 163 responded, representing all but two units. Data were analysed descriptively and through multiple linear regression. Results: A majority (88%) considered Riksstroke data to facilitate detection of stroke care improvement needs and acknowledged that their data motivated quality improvements (78%). The use of Riksstroke for quality improvement initiatives was associated (R2=0.76) with ‘Colleagues’ call for local results’ (p=<0.001), ‘Management Request of Registry data’ (p=<0.001), and it was said to be ‘Simple to explain the results to colleagues’ (p=0.02). Using stepwise regression, ‘Colleagues’ call for local results’ was identified as the most influential factor. Yet, while 73% reported that managers request registry data, only 39% reported that their colleagues call for the unit's Riksstroke results. Conclusions: While an NQR like Riksstroke demonstrates improvement needs and motivates stakeholders to make progress, local stroke care staff and managers need to engage to keep the momentum going in terms of applying registry data when planning, performing and evaluating quality initiatives.

För Sverige i framtiden : Bio-objektifiering av ny medicinsk teknologi

Taking Sweden into the future – Bio-objectification of new medical technology In this article, we analyze how contemporary discursive silences around new biotechnologies such as cybrids and induced pluripotent stem cells (iPSC), have been enabled by earlier policy processes in the area, e.g. boundary work around what is human and non-human, living and non-living, subject and object. The analysis of policy processes around xenotransplantations and the use of human embryonic stem cells, shows that the stem cells’ and xenografts’ “bio-identities” become stabilized through high expectations for the future, a lack of therapeutic possibilities and struggles over definitions of life. The policy processes around human embryonic stem cells and organs from other animals, are characterized by a normalization of certain understandings of ”life”, trust in scientific progress and it’s national financial potentials and a categorization of criticism as irrational. Through these “bio-objectification processes”, debate and decision making has been moved from a political and public context into ethical committees and research funding bodies. The article concludes by discussing consequences of this political non-handling of biomedical technologies and how these bioobjects could be re-politicized.

What aspects of rehabilitation provision contribute to self-reported met needs for rehabilitation one year after stroke - amount, place, operator or timing?

BACKGROUND AND OBJECTIVE: To a large extent, people who have suffered a stroke report unmet needs for rehabilitation. The purpose of this study was to explore aspects of rehabilitation provision that potentially contribute to self-reported met needs for rehabilitation 12 months after stroke with consideration also to severity of stroke. METHODS: The participants (n = 173) received care at the stroke units at the Karolinska University Hospital, Sweden. Using a questionnaire, the dependent variable, self-reported met needs for rehabilitation, was collected at 12 months after stroke. The independent variables were four aspects of rehabilitation provision based on data retrieved from registers and structured according to four aspects: amount of rehabilitation, service level (day care rehabilitation, primary care rehabilitation and home-based rehabilitation), operator level (physiotherapist, occupational therapist, speech therapist) and time after stroke onset. Multivariate logistic regression analyses regarding the aspects of rehabilitation were performed for the participants who were divided into three groups based on stroke severity at onset. RESULTS: Participants with moderate/severe stroke who had seen a physiotherapist at least once during each of the 1st, 2nd and 3rd-4th quarters of the first year (OR 8.36, CI 1.40-49.88 P = 0.020) were more likely to report met rehabilitation needs. CONCLUSION: For people with moderate/severe stroke, continuity in rehabilitation (preferably physiotherapy) during the first year after stroke seems to be associated with self-reported met needs for rehabilitation.

Systematic work environment management : experiences from implementation in Swedish small-scale enterprises

Small-scale enterprises face difficulties in fulfilling the regulations for organising Systematic Work Environment Management. This study compared three groups of small-scale manufacturing enterprises with and without support for implementing the provision. Two implementation methods, supervised and network method, were used. The third group worked according to their own ideas. Twenty-three enterprises participated. The effects of the implementation were evaluated after one year by semi-structured dialogue with the manager and safety representative. Each enterprise was classified on compliance with ten demands concerning the provision. The work environment was estimated by the WEST-method. Impact of the implementation on daily work was also studied. At the follow-up, the enterprises in the supervised method reported slightly more improvements in the fulfilment of the demands in the provision than the enterprises in the network method and the enterprises working on their own did. The effect of the project reached the employees faster in the enterprises with the supervised method. In general, the work environment improved to some extent in all enterprises. Extensive support to small-scale enterprises in terms of advise and networking aimed to fulfil the regulations of Systematic Work Environment Management had limited effect especially considering the cost of applying these methods.

How single is ‘single’ : some pragmatic reflections on single versus multifaceted interventions to facilitate implementation

An earlier overview of systematic reviews and a subsequent editorial on single-component versus multifaceted interventions to promote knowledge translation (KT) highlight complex issues in implementation science. In this supplemented commentary, further aspects are in focus; we propose examples from (KT) studies probing the issue of single interventions. A main point is that defining what is a single and what is a multifaceted intervention can be ambiguous, depending on how the intervention is conceived. Further, we suggest additional perspectives in terms of strategies to facilitate implementation. More specifically, we argue for a need to depict not only what activities are done in implementation interventions, but to unpack functions in particular contexts, in order to support the progress of implementation science.

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.

The importance of considering the evidence in the MTP 2014 Amendment debate in India - unsubstantiated arguments should not impede improved access to safe abortion

With the objective to improve access to safe abortion services in India, the Ministry of Health and Welfare, with approval of the Law Ministry, published draft amendments of the MTP Act on October 29, 2014. Instead of the expected support, the amendments created a heated debate within professional medical associations of India. In this commentary, we review the evidence in response to the current discourse with regard to the amendments. It would be unfortunate if unsubstantiated one-sided arguments would impede the intention of improving access to safe abortion care in India.