Being a bridge : Swedish antenatal care midwives’ encounters with Somali-born women and questions of violence; a qualitative study

Background: Violence against women is associated with serious health problems, including adverse maternal and child health. Antenatal care (ANC) midwives are increasingly expected to implement the routine of identifying exposure to violence. An increase of Somali born refugee women in Sweden, their reported adverse childbearing health and possible links to violence pose a challenge to the Swedish maternity health care system. Thus, the aim was to explore ways ANC midwives in Sweden work with Somali born women and the questions of exposure to violence. Methods: Qualitative individual interviews with 17 midwives working with Somali-born women in nine ANC clinics in Sweden were analyzed using thematic analysis. Results: The midwives strived to focus on the individual woman beyond ethnicity and cultural differences. In relation to the Somali born women, they navigated between different definitions of violence, ways of handling adversities in life and social contexts, guided by experience based knowledge and collegial support. Seldom was ongoing violence encountered. The Somali-born women’s’ strengths and contentment were highlighted, however, language skills were considered central for a Somali-born woman’s access to rights and support in the Swedish society. Shared language, trustful relationships, patience, and networking were important aspects in the work with violence among Somali-born women. Conclusion: Focus on the individual woman and skills in inter-cultural communication increases possibilities of overcoming social distances. This enhances midwives’ ability to identify Somali born woman’s resources and needs regarding violence disclosure and support. Although routine use of professional interpretation is implemented, it might not fully provide nuances and social safety needed for violence disclosure. Thus, patience and trusting relationships are fundamental in work with violence among Somali born women. In collaboration with social networks and other health care and social work professions, the midwife can be a bridge and contribute to increased awareness of rights and support for Somali-born women in a new society.

Exploring the influence of context in a community-based facilitation intervention focusing on neonatal health and survival in Vietnam : a qualitative study

Background In the Neonatal health – Knowledge into Practice (NeoKIP) trial in Vietnam, local stakeholder groups, supported by trained laywomen acting as facilitators, promoted knowledge translation (KT) resulting in decreased neonatal mortality. In general, as well as in the community-based NeoKIP trial, there is a need to further understand how context influences KT interventions in low- and middle-income countries (LMICs). Thus, the objective of this study was to explore the influence of context on the facilitation process in the NeoKIP intervention. Methods A secondary content analysis was performed on 16 Focus Group Discussions with facilitators and participants of the stakeholder groups, applying an inductive approach to the content on context through naïve understanding and structured analysis. Results The three main-categories of context found to influence the facilitation process in the NeoKIP intervention were: (1) Support and collaboration of local authorities and other communal stakeholders; (2) Incentives to, and motivation of, participants; and (3) Low health care coverage and utilization. In particular, the role of local authorities in a KT intervention was recognized as important. Also, while project participants expected financial incentives, non-financial benefits such as individual learning were considered to balance the lack of reimbursement in the NeoKIP intervention. Further, project participants recognized the need to acknowledge the needs of disadvantaged groups. Conclusions This study provides insight for further understanding of the influence of contextual aspects to improve effects of a KT intervention in Vietnam. We suggest that future KT interventions should apply strategies to improve local authorities’ engagement, to identify and communicate non-financial incentives, and to make disadvantaged groups a priority. Further studies to evaluate the contextual aspects in KT interventions in LMICs are also needed.

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.

Local politico-administrative perspectives on quality improvement based on national registry data in Sweden : a qualitative study using the Consolidated Framework for Implementation Research.

Background. Through a national policy agreement, over 167 million Euros will be invested in the Swedish National Quality Registries (NQRs) between 2012 and 2016. One of the policy agreement¿s intentions is to increase the use of NQR data for quality improvement (QI). However, the evidence is fragmented as to how the use of medical registries and the like lead to quality improvement, and little is known about non-clinical use. The aim was therefore to investigate the perspectives of Swedish politicians and administrators on quality improvement based on national registry data. Methods. Politicians and administrators from four county councils were interviewed. A qualitative content analysis guided by the Consolidated Framework for Implementation Research (CFIR) was performed. Results. The politicians and administrators perspectives on the use of NQR data for quality improvement were mainly assigned to three of the five CFIR domains. In the domain of intervention characteristics, data reliability and access in reasonable time were not considered entirely satisfactory, making it difficult for the politico-administrative leaderships to initiate, monitor, and support timely QI efforts. Still, politicians and administrators trusted the idea of using the NQRs as a base for quality improvement. In the domain of inner setting, the organizational structures were not sufficiently developed to utilize the advantages of the NQRs, and readiness for implementation appeared to be inadequate for two reasons. Firstly, the resources for data analysis and quality improvement were not considered sufficient at politico-administrative or clinical level. Secondly, deficiencies in leadership engagement at multiple levels were described and there was a lack of consensus on the politicians¿ role and level of involvement. Regarding the domain of outer setting, there was a lack of communication and cooperation between the county councils and the national NQR organizations. Conclusions. The Swedish experiences show that a government-supported national system of well-funded, well-managed, and reputable national quality registries needs favorable local politico-administrative conditions to be used for quality improvement; such conditions are not yet in place according to local politicians and administrators.

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.

Struggling with daily life and enduring pain : a qualitative study of women's experiences with pelvic girdle pain during pregnancy

Background. Few studies have investigated the experiences of living with pelvic girdle pain (PGP) and its impact on pregnant women’s lives. To address this gap in knowledge, this study investigates the experiences of women living with PGP during pregnancy. Methods. A purposive sample, of nine pregnant women with diagnosed PGP, were interviewed about their experiences. Interviews were recorded, transcribed to text and analysed using a Grounded Theory approach. Results. The core category that evolved from the analysis of experiences of living with PGP in pregnancy was “struggling with daily life and enduring pain”. Three properties addressing the actions caused by PGP were identified: i) grasping the incomprehensible; ii) balancing support and dependence and iii) managing the losses. These experiences expressed by the informants constitute a basis for the consequences of PGP: iv) enduring pain; v) being a burden; vi) calculating the risks and the experiences of the informants as vii) abdicating as a mother. Finally, the informants’ experiences of the consequences regarding the current pregnancy and any potential future pregnancies is presented in viii) paying the price and reconsidering the future. A conceptual model of the actions and consequences experienced by the pregnant informants living with PGP is presented. Conclusions. PGP during pregnancy greatly affects the informant’s experiences of her pregnancy, her roles in relationships, and her social context. For informants with young children, PGP negatively affects the role of being a mother, a situation that further strains the experience. As the constant pain disturbs most aspects of the lives of the informants, improvements in the treatment of PGP is of importance as to increase the quality of life. This pregnancy-related condition is prevalent and must be considered a major public health concern during pregnancy.

'Ultrasound is an invaluable third eye, but it can't see everything' : a qualitative study with obstetricians in Australia

Background: Obstetric ultrasound has come to play a significant role in obstetrics since its introduction in clinical care. Today, most pregnant women in the developed world are exposed to obstetric ultrasound examinations, and there is no doubt that the advantages of obstetric ultrasound technique have led to improvements in pregnancy outcomes. However, at the same time, the increasing use has also raised many ethical challenges. This study aimed to explore obstetricians' experiences of the significance of obstetric ultrasound for clinical management of complicated pregnancy and their perceptions of expectant parents' experiences. Methods: A qualitative study was undertaken in November 2012 as part of the CROss-Country Ultrasound Study (CROCUS). Semi-structured individual interviews were held with 14 obstetricians working at two large hospitals in Victoria, Australia. Transcribed data underwent qualitative content analysis. Results: An overall theme emerged during the analyses, 'Obstetric ultrasound - a third eye', reflecting the significance and meaning of ultrasound in pregnancy, and the importance of the additional information that ultrasound offers clinicians managing the surveillance of a pregnant woman and her fetus. This theme was built on four categories: I:'Everyday-tool' for pregnancy surveillance, II: Significance for managing complicated pregnancy, III: Differing perspectives on obstetric ultrasound, and IV: Counselling as a balancing act. In summary, the obstetricians viewed obstetric ultrasound as an invaluable tool in their everyday practice. More importantly however, the findings emphasise some of the clinical dilemmas that occur due to its use: the obstetricians' and expectant parents' differing perspectives and expectations of obstetric ultrasound examinations, the challenges of uncertain ultrasound findings, and how this information was conveyed and balanced by obstetricians in counselling expectant parents. Conclusions: This study highlights a range of previously rarely acknowledged clinical dilemmas that obstetricians face in relation to the use of obstetric ultrasound. Despite being a tool of considerable significance in the surveillance of pregnancy, there are limitations and uncertainties that arise with its use that make counselling expectant parents challenging. Research is needed which further investigates the effects and experiences of the continuing worldwide rapid technical advances in surveillance of pregnancies.

What is important for you? A qualitative interview study of living with diabetes and experiences of diabetes care to establish a basis for a tailored Patient-Reported Outcome Measure for the Swedish National Diabetes Register

OBJECTIVES: There is a growing emphasis on the perspective of individuals living with diabetes and the need for a more person-centred diabetes care. At present, the Swedish National Diabetes Register (NDR) lacks patient-reported outcome measures (PROMs) based on the perspective of the patient. As a basis for a new PROM, the aim of this study was to describe important aspects in life for adult individuals with diabetes. DESIGN: Semistructured qualitative interviews analysed using content analysis. SETTING: Hospital-based outpatient clinics and primary healthcare clinics in Sweden. PARTICIPANTS: 29 adults with type 1 diabetes mellitus (DM) (n=15) and type 2 DM (n=14). INCLUSION CRITERIA: Swedish adults (≥18 years) living with type 1 DM or type 2 DM (duration ≥5 years) able to describe their situation in Swedish. Purposive sampling generated heterogeneous characteristics. RESULTS: To live a good life with diabetes is demanding for the individual, but experienced barriers can be eased by support from others in the personal sphere, and by professional support from diabetes care. Diabetes care was a crucial resource to nurture the individual's ability and knowledge to manage diabetes, and to facilitate life with diabetes by supplying support, guidance, medical treatment and technical devices tailored to individual needs. The analysis resulted in the overarching theme 'To live a good life with diabetes' constituting the two main categories 'How I feel and how things are going with my diabetes' and 'Support from diabetes care in managing diabetes' including five different categories. CONCLUSIONS: Common aspects were identified including the experience of living with diabetes and support from diabetes care. These will be used to establish a basis for a tailored PROM for the NDR.

Can humming caregivers´ facilitate feeding during mealtime situations with persons with dementia? A qualitative study

Background. ‘Music Therapeutic Caregiving’, defined as when caregivers’ sing for or together with persons with dementia care situations, has been shown to facilitate the caring situation, and enhance positive and decrease negative expressions in persons with dementia. No studies about singing during mealtimes have been conducted, and this project was designed to elucidate this. However, since previous studies have shown that there is a risk that persons with dementia will start to sing along with the caregiver, the caregiver in this study hummed such that the person with dementia did not sing instead of eat. Aim. To describe professional caregivers’ experiences of humming during meal time while feeding persons with dementia. Method. An intervention with caregivers humming was implemented during lunch time. Focus group interviews were conducted to fetch the caregivers experiences. Qualitative content analysis was used to analyse the interviews. Results. The caregivers described that humming disseminated relaxation and joy, and awakened memories about the songs hummed which encouraged the persons with the dementia to join in the songs. They also described that humming seemed to make the persons with dementia associate with mealtime and could make them eat more. However it also revealed suspiciousness and agitation from the persons with dementia. Conclusion. Humming during mealtime revealed mainly positive as well as some negative influences. More and larger studies are needed to be able to draw general conclusions.

Healthcare providers balancing norms and practice : challenges and opportunities in providing contraceptive counselling to young people in Uganda - a qualitative study

BACKGROUND: Pregnancies among young women force girls to compromise education, resulting in low educational attainment with subsequent poverty and vulnerability. A pronounced focus is needed on contraceptive use, pregnancy, and unsafe abortion among young women. OBJECTIVE: This study aims to explore healthcare providers' (HCPs) perceptions and practices regarding contraceptive counselling to young people. DESIGN: We conducted 27 in-depth interviews with doctors and midwives working in seven health facilities in central Uganda. Interviews were open-ended and allowed the participant to speak freely on certain topics. We used a topic guide to cover areas topics of interest focusing on post-abortion care (PAC) but also covering contraceptive counselling. Transcripts were transcribed verbatim and data were analysed using thematic analysis. RESULTS: The main theme, HCPs' ambivalence to providing contraceptive counselling to sexually active young people is based on two sub-themes describing the challenges of contraceptive counselling: A) HCPs echo the societal norms regarding sexual practice among young people, while at the same time our findings B) highlights the opportunities resulting from providers pragmatic approach to contraceptive counselling to young women. Providers expressed a self-identified lack of skill, limited resources, and inadequate support from the health system to successfully provide appropriate services to young people. They felt frustrated with the consultations, especially when meeting young women seeking PAC. CONCLUSIONS: Despite existing policies for young people's sexual and reproductive health in Uganda, HCPs are not sufficiently equipped to provide adequate contraceptive counselling to young people. Instead, HCPs are left in between the negative influence of social norms and their pragmatic approach to address the needs of young people, especially those seeking PAC. We argue that a clear policy supported by a clear strategy with practical guidelines should be implemented alongside in-service training including value clarification and attitude transformation to equip providers to be able to better cater to young people seeking sexual and reproductive health advice.

Towards Qualitative Approaches to Bayesian Evidential Reasoning

A crucial aspect of evidential reasoning in crime investigation involves comparing the support that evidence provides for alternative hypotheses. Recent work in forensic statistics has shown how Bayesian Networks (BNs) can be employed for this purpose. However, the specification of BNs requires conditional probability tables describing the uncertain processes under evaluation. When these processes are poorly understood, it is necessary to rely on subjective probabilities provided by experts. Accurate probabilities of this type are normally hard to acquire from experts. Recent work in qualitative reasoning has developed methods to perform probabilistic reasoning using coarser representations. However, the latter types of approaches are too imprecise to compare the likelihood of alternative hypotheses. This paper examines this shortcoming of the qualitative approaches when applied to the aforementioned problem, and identifies and integrates techniques to refine them.

On Qualitative Probabilities for Legal Reasoning about Evidence

A crucial aspect of evidential reasoning in crime investigation involves comparing the support that evidence provides for alternative hypotheses. Recent work in forensic statistics has shown how Bayesian Networks (BNs) can be employed for this purpose. However, the specification of BNs requires conditional probability tables describing the uncertain processes under evaluation. When these processes are poorly understood, it is necessary to rely on subjective probabilities provided by experts. Accurate probabilities of this type are normally hard to acquire from experts. Recent work in qualitative reasoning has developed methods to perform probabilistic reasoning using coarser representations. However, the latter types of approaches are too imprecise to compare the likelihood of alternative hypotheses. This paper examines this shortcoming of the qualitative approaches when applied to the aforementioned problem, and identifies and integrates techniques to refine them.

Optimal IV estimation of systems with stochastic regressors and var disturbances with applications to dynamic systems

This paper considers the general problem of Feasible Generalized Least Squares Instrumental Variables (FG LS IV) estimation using optimal instruments. First we summarize the sufficient conditions for the FG LS IV estimator to be asymptotic ally equivalent to an optimal G LS IV estimator. Then we specialize to stationary dynamic systems with stationary VAR errors, and use the sufficient conditions to derive new moment conditions for these models. These moment conditions produce useful IVs from the lagged endogenous variables, despite the correlation between errors and endogenous variables. This use of the information contained in the lagged endogenous variables expands the class of IV estimators under consideration and there by potentially improves both asymptotic and small-sample efficiency of the optimal IV estimator in the class. Some Monte Carlo experiments compare the new methods with those of Hatanaka [1976]. For the DG P used in the Monte Carlo experiments, asymptotic efficiency is strictly improved by the new IVs, and experimental small-sample efficiency is improved as well.

Food waste in lower-middle income households: a qualitative analysis of antecedents and a typology of food wasters

Esta dissertação doutoral, com base em dados empíricos coletados com 50 mães distribuídas no Brasil (n = 30) e nos EUA (n = 20), tem como objetivo fornecer uma melhor compreensão do desperdício de alimento no contexto da baixa renda. A tese é composta por três artigos, que combinados, cumprem os objetivos de identificar os antecedentes do desperdício de alimento e delinear uma tipologia dos desperdiçadores de alimento. Adicionalmente, contextualiza o desperdício global e um capítulo propõe uma agenda futura para estudos sobre desperdício de alimento no âmbito do consumidor. O desperdício de alimento nas famílias, enquanto tema de pesquisa, oferece a oportunidade para o trabalho acadêmico em marketing cumprir os critérios de relevância social, gerencial e para políticas públicas. No primeiro estudo, descrevem-se os fatores do chamado "paradoxo do desperdício de alimento", a identificação e análise do desperdício de alimento em famílias com restrições orçamentárias, enquanto apresentam-se o itinerário do consumo de alimentos e os antecedentes do desperdício. Este primeiro artigo, elaborado com dados coletados em famílias brasileiras, ilustra também o papel das normas culturais, tais como o preparo abundante de alimento para mostrar hospitalidade ou como forma de não ser percebido como pobre, no aumento do desperdício. No segundo artigo, uma grounded-theory (teoria fundamentada nos dados) destaca o papel do afeto e da abundância no desperdício de alimento familiar. Para enriquecer as contribuições teóricas, este segundo estudo apresenta um framework com seis dimensões do desperdício de alimento (1. Afeto; 2. Abundância; 3. Multiplicidade de escolhas; 4. Conveniência; 5. Procrastinação; 6. Rotina sem planejamento). Baseado em dados empíricos coletados em famílias americanas, este estudo proporciona novas explicações, a exemplo de como o estoque abundante de comfort foods - uma forma de impulsionar tanto emoções positivas para si quanto mostrar afeto para crianças – pode gerar mais desperdício de alimentos. Em síntese, o segundo artigo identifica uma consequência negativa do afeto e da abundância de alimentos no contexto familiar, e apresenta um framework teoricamente relevante. Finalmente, o terceiro artigo, a partir do conjunto de dados dos estudos anteriores e de nova coleta com dez famílias, propõe uma tipologia comportamental do desperdício de alimento, uma contribuição original aos estudos de comportamento do consumidor. A identificação de cinco tipos de desperdiçadores de alimentos - (1) Mães carinhosas; (2) Cozinheiras abundantes; (3) Desperdiçadoras de sobras; (4) Procrastinadoras; (5) Mães versáteis - contribui para a teoria, enquanto implicações potenciais para educadores nutricionais e agentes públicos são exploradas a partir dos resultados. Como uma forma de explicar as características de cada um dos cinco tipos identificados, compara-se aspectos das amostras brasileira e norte-americana, que apresentam similaridades no comportamento de desperdício de alimento. Os níveis de desperdício percebidos por país também são comparados. Em suma, os achados dos três artigos podem contribuir para maximizar os resultados de campanhas de conscientização voltadas à mitigação do desperdício de alimento, e apresentam ideias para varejistas interessados em iniciativas de sustentabilidade. Mais abrangentemente, os resultados apresentados também podem ser aplicados para incrementar programas de combate à fome e projetos de educação nutricional realizados pelo setor público ou ONGs.

A qualitative study of the internationalization of born-global technology start-ups in Brazil

O fenômeno das empresas born globals e a internacionalização de empresas brasileiras de base tecnológica são tópicos recentes na literatura acadêmica, devido também ao fenômeno ser recente. Não existem muitos estudados feitos com foco no mercado brasileiro, e os poucos que foram feitos, possuem um viés quantitativo. Esse estudo, entretanto, tem como objetivo analisar startups de maneira qualitativa. Uma extensa revisão de literatura foi desenvolvida a fim de melhor analisar as fundações nas quais o estudo seria desenvolvido, revisando os métodos de internacionalização, empreendedorismo no Brasil, e o fenômeno born global no geral. Entrevistas foram conduzidas com empreendedores no Brasil, que passaram pelo processo de internacionalização de seus modelos de negócios, a fim de reunir introspecções a respeito das peculiaridades do mercado brasileiro. Foram também analisados os fatores de escalabilidade de modelos de negócios dependentes de tecnologia, motivadores para a internacionalização, critério de seleção de mercados, programas governamentais, e o papel das startups brasileiras em uma perspectiva global.